Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 25239 | TX |
NPI | 1104016344 |
---|---|
Provider Name | Kristine Donnelly |
First Address | San Antonio, TX 78221-1650 |
Second Address | Bryan, TX 77802-2329 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2007 |
Last Update Date | 26/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
209944216 | (05) | TX |
379870403 | (05) | TX |