Provider Demographics
NPI:1679799431
Name:KRISTOVICH, ANN H (DDS)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:H
Last Name:KRISTOVICH
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 1:901 W 38TH ST STE 410
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1162
Mailing Address - Country:US
Mailing Address - Phone:512-992-1378
Mailing Address - Fax:
Practice Address - Street 1:901 W 38TH ST STE 410
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-992-1378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11503204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX008355204Medicaid
TX43319YKZJOtherMEDICARE