Basic Information
Provider Information
NPI: 1073063236
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PIETILA
FirstName: KRISTA
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 894 CAMPUS DR
Address2: STE B
City: HANCOCK
State: MI
PostalCode: 499301644
CountryCode: US
TelephoneNumber: 9064831445
FaxNumber: 9064831122
Practice Location
Address1: 56901 S 6TH ST
Address2: STE 1 & 2
City: CALUMET
State: MI
PostalCode: 499132946
CountryCode: US
TelephoneNumber: 9064831177
FaxNumber: 9064831188
Other Information
ProviderEnumerationDate: 10/11/2016
LastUpdateDate: 10/11/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X MIY Dental ProvidersDental Hygienist 

No ID Information.


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