=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649582479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN S KROCHMAL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2010
-----------------------------------------------------
Last Update Date | 06/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 LAKEVIEW RD
-----------------------------------------------------
City | WAYLAND
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01778-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-636-0378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 LAKEVIEW RD
-----------------------------------------------------
City | WAYLAND
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01778-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1855909
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------