1649343682 NPI number — KEITH SCOTT CRAWFORD DMD

Table of content: KEITH SCOTT CRAWFORD DMD (NPI 1649343682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649343682 NPI number — KEITH SCOTT CRAWFORD DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAWFORD
Provider First Name:
KEITH
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649343682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2711 LOVEJOY CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-474-0622
Provider Business Mailing Address Fax Number:
770-417-3500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 HOLCOMB BRIDGE ROAD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
NORCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-447-5311
Provider Business Practice Location Address Fax Number:
770-417-3500
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  9310 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00217797B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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