Provider Demographics
NPI:1649817719
Name:CRENTIST PC
Entity type:Organization
Organization Name:CRENTIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLINKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-523-9800
Mailing Address - Street 1:1100 MACDADE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODLYN
Mailing Address - State:PA
Mailing Address - Zip Code:19094-1322
Mailing Address - Country:US
Mailing Address - Phone:610-833-1919
Mailing Address - Fax:
Practice Address - Street 1:1100 MACDADE BLVD
Practice Address - Street 2:
Practice Address - City:WOODLYN
Practice Address - State:PA
Practice Address - Zip Code:19094-1322
Practice Address - Country:US
Practice Address - Phone:610-833-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-07
Last Update Date:2019-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental