Healthcare Provider Details

I. General information

NPI: 1932214301
Provider Name (Legal Business Name): CHARLES MORTON KROWICKI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 MAIN STREET
LEBANON NJ
08833
US

IV. Provider business mailing address

63 MAIN STREET PO BOX 545
LEBANON NJ
08833
US

V. Phone/Fax

Practice location:
  • Phone: 908-236-2802
  • Fax: 908-236-7154
Mailing address:
  • Phone: 908-537-2447
  • Fax: 908-236-7154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI01084100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: