Provider Demographics
NPI:1902427560
Name:KVAS, KHRYSTYNA
Entity Type:Individual
Prefix:
First Name:KHRYSTYNA
Middle Name:
Last Name:KVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9747 REDD RAMBLER DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2925
Mailing Address - Country:US
Mailing Address - Phone:215-285-5125
Mailing Address - Fax:
Practice Address - Street 1:6412 FRANKFORD AVE # 10
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-3005
Practice Address - Country:US
Practice Address - Phone:215-285-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0427311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program