=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407234248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER CRISS, DDS,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2015
-----------------------------------------------------
Last Update Date | 05/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1602 E STARR AVE SUITE 203
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-559-7200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1602 E STARR AVE SUITE 203
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-559-7200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JENNFIER CRISS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 936-559-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 21417
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 21417
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------