Provider Demographics
NPI:1750110581
Name:CRYSTAL CLEAR DENTAL SPA LLC
Entity type:Organization
Organization Name:CRYSTAL CLEAR DENTAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIANGIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-731-2162
Mailing Address - Street 1:7933 BAYMEADOWS WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7514
Mailing Address - Country:US
Mailing Address - Phone:904-731-2162
Mailing Address - Fax:
Practice Address - Street 1:7933 BAYMEADOWS WAY STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7514
Practice Address - Country:US
Practice Address - Phone:904-731-2162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental