Provider Demographics
NPI:1902117807
Name:DECLERCK, KRYSTAL DAWN (DDS)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:DAWN
Last Name:DECLERCK
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 1:3000 ARLINGTON AVE
Mailing Address - Street 2:GRADUATE MEDICAL EDUCATION, MS 1050
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2595
Mailing Address - Country:US
Mailing Address - Phone:419-383-4244
Mailing Address - Fax:419-383-3108
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION, MS 1050
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-4244
Practice Address - Fax:419-383-3108
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.2951390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program