Provider Demographics
NPI:1952642571
Name:REYES VIRUET, KRYSTAL (DMD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:REYES VIRUET
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BERGEN ST
Mailing Address - Street 2:D-881
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2495
Mailing Address - Country:US
Mailing Address - Phone:973-972-6613
Mailing Address - Fax:
Practice Address - Street 1:34 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7530
Practice Address - Country:US
Practice Address - Phone:239-275-6564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN229821223P0300X, 1223P0300X
PR34291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics