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General NPI Number Information
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NPI Number | 1417110537
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Entity Type | Organization
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Legal Business Name | KRYSTAL CLEAR DENTAL P.L.
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Dates
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Enumeration Date | 07/09/2008
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Last Update Date | 07/09/2008
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Provider Practice Location Address
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Address Line | 19445 SHUMARD OAK DR
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City | LAND O LAKES
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State | FL
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Zip | 34638-7262
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Country | US
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Telephone | 813-849-3695
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Fax |
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Provider Business Mailing Address
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Address Line | 18838 DUQUESNE DR
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City | TAMPA
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State | FL
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Zip | 33647-3421
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Country | US
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Telephone | 813-849-3695
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KRYSTELLE TERRY DUVERT
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Credential | DDS
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Telephone | 813-849-3695
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 16987
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License Number State | FL
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