Healthcare Provider Details

I. General information

NPI: 1386061349
Provider Name (Legal Business Name): DR. CRAIG LUSTMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8903 GLADES RD STE D4
BOCA RATON FL
33434-4023
US

IV. Provider business mailing address

8903 GLADES RD STE D4
BOCA RATON FL
33434-4023
US

V. Phone/Fax

Practice location:
  • Phone: 561-483-9334
  • Fax:
Mailing address:
  • Phone: 561-483-9334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD21099
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD039540
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: