Provider Demographics
NPI:1073731022
Name:KROMBACH, MICHAEL A
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:KROMBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1774 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8929
Mailing Address - Country:US
Mailing Address - Phone:904-725-7085
Mailing Address - Fax:904-725-6751
Practice Address - Street 1:1774 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8929
Practice Address - Country:US
Practice Address - Phone:904-725-7085
Practice Address - Fax:904-725-6751
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN000099461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice