Provider Demographics
NPI:1528767977
Name:MYRICK, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MYRICK
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 1:757 CONGDON ST W
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 HEMINGWAY AVE
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-3000
Practice Address - Country:US
Practice Address - Phone:203-469-5644
Practice Address - Fax:203-469-1067
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist