Provider Demographics
NPI:1003830134
Name:CRUNK, BENJAMIN ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ALAN
Last Name:CRUNK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVALLO
Mailing Address - State:AL
Mailing Address - Zip Code:35115-3847
Mailing Address - Country:US
Mailing Address - Phone:205-665-2031
Mailing Address - Fax:205-665-5560
Practice Address - Street 1:980 MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTEVALLO
Practice Address - State:AL
Practice Address - Zip Code:35115-3847
Practice Address - Country:US
Practice Address - Phone:205-665-2031
Practice Address - Fax:205-665-5560
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL40041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-03995OtherBC/BS OF AL PROVIDER #
AL510-03995OtherBC/BS OF AL PROVIDER #