Provider Demographics
NPI:1295191161
Name:MEDFORD FAMILY AND COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:MEDFORD FAMILY AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUSINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-654-2520
Mailing Address - Street 1:353 ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9583
Mailing Address - Country:US
Mailing Address - Phone:609-654-2520
Mailing Address - Fax:609-654-5886
Practice Address - Street 1:353 ROUTE 70
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9583
Practice Address - Country:US
Practice Address - Phone:609-654-2520
Practice Address - Fax:609-654-5886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI017376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty