Provider Demographics
NPI:1306560362
Name:PETERS, CRYSTAL RENEE' (DDS)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:RENEE'
Last Name:PETERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25120 PANTHER BEND CT APT 213
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-4196
Mailing Address - Country:US
Mailing Address - Phone:317-989-2392
Mailing Address - Fax:
Practice Address - Street 1:2604 ALDRICH ST STE A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3484
Practice Address - Country:US
Practice Address - Phone:512-843-7768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice