Healthcare Provider Details

I. General information

NPI: 1619591229
Provider Name (Legal Business Name): ROSSANA CRUCIATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2020
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MAPLE AVE
RED BANK NJ
07701-1733
US

IV. Provider business mailing address

39 HILLTOP TER
STATEN ISLAND NY
10304-1108
US

V. Phone/Fax

Practice location:
  • Phone: 732-747-1122
  • Fax:
Mailing address:
  • Phone: 347-609-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS042584
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02832200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: