Provider Demographics
NPI:1609565258
Name:QUEEN CITY ORTHODONTICS
Entity Type:Organization
Organization Name:QUEEN CITY ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTICS
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRASTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:567-454-0273
Mailing Address - Street 1:9856 SNIDER RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-9323
Mailing Address - Country:US
Mailing Address - Phone:567-454-0273
Mailing Address - Fax:
Practice Address - Street 1:6752 CINCINNATI DAYTON RD STE 102A
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-9325
Practice Address - Country:US
Practice Address - Phone:513-434-8320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental