Provider Demographics
NPI:1962841205
Name:GLEASON, KRISTINE A (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:A
Last Name:GLEASON
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:992 MANTUA PIKE
Mailing Address - Street 2:STE 302
Mailing Address - City:WOODBURY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08097-1249
Mailing Address - Country:US
Mailing Address - Phone:215-662-3586
Mailing Address - Fax:
Practice Address - Street 1:992 MANTUA PIKE STE 302
Practice Address - Street 2:
Practice Address - City:WOODBURY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08097-1249
Practice Address - Country:US
Practice Address - Phone:856-845-1341
Practice Address - Fax:856-384-9067
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI028275001223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22-2218302OtherFEIN