Provider Demographics
NPI:1104483122
Name:BRISTLIN, MEGHAN CYRENA (DMD)
Entity type:Individual
Prefix:DR
First Name:MEGHAN
Middle Name:CYRENA
Last Name:BRISTLIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3326 4TH ST STE 3
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4455
Mailing Address - Country:US
Mailing Address - Phone:208-746-2414
Mailing Address - Fax:
Practice Address - Street 1:3326 4TH ST STE 3
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4455
Practice Address - Country:US
Practice Address - Phone:208-746-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD50301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice