Provider Demographics
NPI:1063057818
Name:KRUTER ERIJMAN, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:KRUTER ERIJMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-4836
Mailing Address - Country:US
Mailing Address - Phone:978-282-8899
Mailing Address - Fax:781-581-9583
Practice Address - Street 1:302 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-4836
Practice Address - Country:US
Practice Address - Phone:978-282-8899
Practice Address - Fax:781-581-9583
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL100183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist