Provider Demographics
NPI:1285788273
Name:KRISWANDI, CRYSTAL DEWI ROSLINA (DMD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:DEWI ROSLINA
Last Name:KRISWANDI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:DR
Other - Last Name:KRISWANDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:503-952-2164
Mailing Address - Fax:503-526-4418
Practice Address - Street 1:7095 SW GONZAGA ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8309
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD76211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice