Provider Demographics
NPI:1124530191
Name:SHINNICK, KRISTIN MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:MARIE
Last Name:SHINNICK
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 1:208 HOSPITAL DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5068
Mailing Address - Country:US
Mailing Address - Phone:850-243-8124
Mailing Address - Fax:
Practice Address - Street 1:208 HOSPITAL DR NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5068
Practice Address - Country:US
Practice Address - Phone:850-243-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL137221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice