Healthcare Provider Details

I. General information

NPI: 1063057818
Provider Name (Legal Business Name): MARINA KRUTER ERIJMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 WASHINGTON ST
GLOUCESTER MA
01930-4836
US

IV. Provider business mailing address

302 WASHINGTON ST
GLOUCESTER MA
01930-4836
US

V. Phone/Fax

Practice location:
  • Phone: 978-282-8899
  • Fax: 781-581-9583
Mailing address:
  • Phone: 978-282-8899
  • Fax: 781-581-9583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL100183
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: