Provider Demographics
NPI:1285945089
Name:SIVANICH, KRISTOFER PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTOFER
Middle Name:PAUL
Last Name:SIVANICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36014 WRATTEN DR
Mailing Address - Street 2:FORT HOOD DENTAC
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:763-670-7386
Mailing Address - Fax:
Practice Address - Street 1:4431 68TH ST
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5042
Practice Address - Country:US
Practice Address - Phone:254-286-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND128361223P0221X
TX262951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry