Provider Demographics
NPI:1215672464
Name:WENER, KRISTINA MARIE
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:WENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8557 VAN AMBER RD
Mailing Address - Street 2:
Mailing Address - City:CASTORLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13620-1207
Mailing Address - Country:US
Mailing Address - Phone:315-317-6144
Mailing Address - Fax:
Practice Address - Street 1:10590 ENDURING FREEDOM DR BLDG P
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5503
Practice Address - Country:US
Practice Address - Phone:315-772-5576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020796124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist