Basic Information
| Provider Information | |||||||||
| NPI: | 1285945089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIVANICH | ||||||||
| FirstName: | KRISTOFER | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36014 WRATTEN DR | ||||||||
| Address2: | FORT HOOD DENTAC | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636707386 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4431 68TH ST | ||||||||
| Address2: | |||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765445042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542867401 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2010 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | D12836 | MN | Y | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 26295 | TX | N | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.