Provider Demographics
NPI:1215913900
Name:CRESTWOOD FAMILY DENTAL
Entity type:Organization
Organization Name:CRESTWOOD FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-914-1039
Mailing Address - Street 1:16 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-7643
Mailing Address - Country:US
Mailing Address - Phone:732-914-1039
Mailing Address - Fax:732-914-8472
Practice Address - Street 1:70 LACEY RD
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:NJ
Practice Address - Zip Code:08759-2931
Practice Address - Country:US
Practice Address - Phone:732-350-7999
Practice Address - Fax:732-350-7961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty