Provider Demographics
NPI:1003978099
Name:CROCKETT, DEIDRE BERGER (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEIDRE
Middle Name:BERGER
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5251 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-4920
Mailing Address - Country:US
Mailing Address - Phone:803-787-9793
Mailing Address - Fax:803-738-0300
Practice Address - Street 1:5251 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-4920
Practice Address - Country:US
Practice Address - Phone:803-787-9793
Practice Address - Fax:803-738-0300
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice