Provider Demographics
NPI:1477696383
Name:SULAK, CRYSTAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:
Last Name:SULAK
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 1:803 COFFEE RD STE 8
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4245
Mailing Address - Country:US
Mailing Address - Phone:209-529-0219
Mailing Address - Fax:
Practice Address - Street 1:803 COFFEE RD STE 8
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4245
Practice Address - Country:US
Practice Address - Phone:209-529-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA407351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice