MEDICARE: EDWARD A. KRUKOWSKI, DMD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	DN11476	FL

General Provider Information

NPI Number	:	1942692223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD A. KRUKOWSKI, DMD, PA

Provider Business Mailing Address
First Line	:	9801 COLLINS AVE
Second Line	:	#C-102
City	:	BAL HARBOUR
State	:	FL
Zip	:	33154-1815
Country	:	US
Telephone Number	:	305-866-6662
Fax Number	:	305-866-1144

Provider Business Practice Location Address
First Line	:	9801 COLLINS AVE
Second Line	:	#C-102
City	:	BAL HARBOUR
State	:	FL
Zip	:	33154-1815
Country	:	US
Telephone Number	:	305-866-6662
Fax Number	:	305-866-1144

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. EDWARD A KRUKOWSKI
Credential	:	DMD
Telephone Number	:	305-866-6662

Provider Enumeration Date	:	02/24/2015
Last Update Date	:	02/24/2015

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