Healthcare Provider Details

I. General information

NPI: 1487735064
Provider Name (Legal Business Name): THOMAS KRAKOWER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 W BALTIMORE PIKE SUITE 2304 RIDDLE HEALTH CARE CENTER II
MEDIA PA
19063-5104
US

IV. Provider business mailing address

1088 W BALTIMORE PIKE STE 2304
MEDIA PA
19063-5136
US

V. Phone/Fax

Practice location:
  • Phone: 610-744-2888
  • Fax: 610-744-2832
Mailing address:
  • Phone: 610-744-2888
  • Fax: 610-744-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS018722L
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: