Provider Demographics
NPI:1538813910
Name:CUSTOM CROWNS
Entity type:Organization
Organization Name:CUSTOM CROWNS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYSHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-788-7779
Mailing Address - Street 1:5202 PLUNKETT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8023
Mailing Address - Country:US
Mailing Address - Phone:305-788-7779
Mailing Address - Fax:
Practice Address - Street 1:5400 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5312
Practice Address - Country:US
Practice Address - Phone:954-947-0641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No291U00000XLaboratoriesClinical Medical Laboratory