Provider Demographics
NPI:1275747305
Name:KRUKOWSKI, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:KRUKOWSKI
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 1:9801 COLLINS AVE
Mailing Address - Street 2:SUITEC-102
Mailing Address - City:BAL HARBOUR
Mailing Address - State:FL
Mailing Address - Zip Code:33154-1815
Mailing Address - Country:US
Mailing Address - Phone:305-866-6662
Mailing Address - Fax:305-866-6662
Practice Address - Street 1:9801 COLLINS AVE
Practice Address - Street 2:SUITEC-102
Practice Address - City:BAL HARBOUR
Practice Address - State:FL
Practice Address - Zip Code:33154-1815
Practice Address - Country:US
Practice Address - Phone:305-866-6662
Practice Address - Fax:305-866-6662
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11476122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist