Provider Demographics
NPI:1053792168
Name:CRISCUOLO, STEPHEN (DMD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:CRISCUOLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 NW 5TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8311 N PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-1539
Practice Address - Country:US
Practice Address - Phone:954-228-7284
Practice Address - Fax:954-314-0575
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN218141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry