Provider Demographics
NPI:1033639463
Name:CRUTCHFIELD PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:CRUTCHFIELD PEDIATRIC DENTAL GROUP
Other - Org Name:ROSEVILLE KIDS DENTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUTCHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:916-773-5230
Mailing Address - Street 1:5420 PARK DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-5562
Mailing Address - Country:US
Mailing Address - Phone:916-435-5230
Mailing Address - Fax:
Practice Address - Street 1:1253 PLEASANT GROVE BLVD STE 190
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-6983
Practice Address - Country:US
Practice Address - Phone:916-773-5230
Practice Address - Fax:916-474-5249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA582111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty