1710101076 NPI number — DR. BENJAMIN CRUSAN D.D.S., P.L.L.C.

Table of content: DR. BENJAMIN CRUSAN D.D.S., P.L.L.C. (NPI 1710101076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710101076 NPI number — DR. BENJAMIN CRUSAN D.D.S., P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRUSAN
Provider First Name:
BENJAMIN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S., P.L.L.C.
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:
1710101076
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:
13204 NW 42ND CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98685-3340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-546-2124
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 SOUTH 56TH PLACE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-887-1177
Provider Business Practice Location Address Fax Number:
360-887-1178
Provider Enumeration Date:
04/11/2007

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:  DE7985 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DE7985 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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