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General NPI Number Information
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NPI Number | 1326654120
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Entity Type | Individual
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Provider Name | KRISTEN DISMORE PA
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Gender | Female
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Dates
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Enumeration Date | 09/17/2020
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Last Update Date | 09/17/2020
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Provider Practice Location Address
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Address Line | 625 BELLE TERRE RD STE 202
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2318
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Country | US
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Telephone | 631-686-7990
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Fax |
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Provider Business Mailing Address
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Address Line | 4 HAZELWOOD AVE APT 1
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City | WESTHAMPTON BEACH
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State | NY
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Zip | 11978-1405
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Country | US
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Telephone | 631-445-1147
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 025086
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License Number State | NY
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