Provider Demographics
NPI:1689397796
Name:CRISTAL PEDIATRIC SMILE
Entity Type:Organization
Organization Name:CRISTAL PEDIATRIC SMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTISTRY
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEJANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-939-0849
Mailing Address - Street 1:7737 N UNIVERSITY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2968
Mailing Address - Country:US
Mailing Address - Phone:215-939-0849
Mailing Address - Fax:
Practice Address - Street 1:7737 N UNIVERSITY DR STE 100
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2968
Practice Address - Country:US
Practice Address - Phone:215-939-0849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1316310303Medicaid