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General NPI Number Information
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NPI Number | 1679280630
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Entity Type | Organization
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Legal Business Name | SURFSIDE SMILE COMPANY LLC
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Dates
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Enumeration Date | 10/31/2022
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Last Update Date | 01/28/2023
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Provider Practice Location Address
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Address Line | 1692 HIGHWAY 35
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City | MIDDLETOWN
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State | NJ
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Zip | 07748
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Country | US
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Telephone | 757-214-1091
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Fax |
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Provider Business Mailing Address
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Address Line | 2404 CHERRY ST
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City | MANASQUAN
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State | NJ
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Zip | 08736-1523
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRISTIANNE MACARAEG KRACKE
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Credential | DMD
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Telephone | 757-214-1091
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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