MEDICARE: MISS KRYSTAL BROOKE EVANS R.D.H., R.D.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	18757	TX
2	126800000X	Dental Assistant	36830	TX

General Provider Information

NPI Number	:	1245654243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KRYSTAL BROOKE EVANS R.D.H., R.D.A.

Provider Business Mailing Address
First Line	:	9113 STELLA LINK RD STE C
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-3931
Country	:	US
Telephone Number	:	713-375-1777
Fax Number	:	832-383-0022

Provider Business Practice Location Address
First Line	:	9113 STELLA LINK RD STE C
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-3931
Country	:	US
Telephone Number	:	713-375-1777
Fax Number	:	832-383-0022

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2014
Last Update Date	:	02/11/2014

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