Provider Demographics
NPI:1538585740
Name:DOERSAM, KRISTOPHER (DDS)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
Last Name:DOERSAM
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 1:401 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-1337
Mailing Address - Country:US
Mailing Address - Phone:570-326-5456
Mailing Address - Fax:570-323-4550
Practice Address - Street 1:2687 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:S WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-6754
Practice Address - Country:US
Practice Address - Phone:570-326-5456
Practice Address - Fax:570-323-4550
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist