Basic Information
| Provider Information | |||||||||
| NPI: | 1841438421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDO | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | SOASH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608858131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1780 OLD HIGHWAY 50 E | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630843397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365828100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901019894 | MI | N | Dental Providers | Dentist | General Practice | 1223G0001X | 2011030116 | MO | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1841438421 | 05 | MO | MEDICAID |