Provider Demographics
NPI:1144341793
Name:DISHAW, KRYSTYN MARIE (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:KRYSTYN
Middle Name:MARIE
Last Name:DISHAW
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:DR
Other - First Name:KRYSTYN
Other - Middle Name:MARIE
Other - Last Name:FRANCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1007 ASHLAWN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1716
Mailing Address - Country:US
Mailing Address - Phone:214-543-1620
Mailing Address - Fax:
Practice Address - Street 1:1007 ASHLAWN DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-1716
Practice Address - Country:US
Practice Address - Phone:214-543-1620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228611223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1479404-03Medicaid
TX1479404-09Medicaid
TX1479404-10Medicaid
TX1479404-04Medicaid
TX1479404-05Medicaid
TX1479404-08Medicaid
TX1479404-12Medicaid
TX1803512-01Medicaid
TX1479404-01Medicaid
TX1479404-06Medicaid
TX1479404-07Medicaid
TX1479404-11Medicaid
TX1803512-02Medicaid