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General NPI Number Information
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NPI Number | 1154062883
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Entity Type | Individual
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Provider Name | KRISTINA MACKENZIE CERAVOLO
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Gender | Female
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 08/14/2023
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Provider Practice Location Address
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Address Line | 2 WASHINGTON AVE
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City | IRVINGTON
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State | NJ
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Zip | 07111-3550
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Country | US
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Telephone | 973-926-5306
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Fax |
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Provider Business Mailing Address
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Address Line | 722-724 ADAMS ST APT 9
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City | HOBOKEN
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State | NJ
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Zip | 07030-2878
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Country | US
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Telephone | 315-256-8181
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22DI02954300
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License Number State | NJ
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