Provider Demographics
NPI:1447394077
Name:KRETZSCHMAR, SAMUEL LEE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LEE
Last Name:KRETZSCHMAR
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 N WICKHAM RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2400
Mailing Address - Country:US
Mailing Address - Phone:321-242-2236
Mailing Address - Fax:321-751-6072
Practice Address - Street 1:4301 N WICKHAM RD
Practice Address - Street 2:SUITE 9
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2400
Practice Address - Country:US
Practice Address - Phone:321-242-2236
Practice Address - Fax:321-751-6072
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 139151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice