1104213636 NPI number — CAMERON CRITCHFIELD DDS

Table of content: CAMERON CRITCHFIELD DDS (NPI 1104213636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104213636 NPI number — CAMERON CRITCHFIELD DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRITCHFIELD
Provider First Name:
CAMERON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1104213636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 SOUTH 2000 EAST, SUITE 5900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-581-8951
Provider Business Mailing Address Fax Number:
801-585-6485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1531 BLEISTEIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CODY
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82414-3806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-587-0100
Provider Business Practice Location Address Fax Number:
307-587-0105
Provider Enumeration Date:
04/22/2015

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: 1223G0001X , with the licence number:  1446 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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