Provider Demographics
NPI:1083638746
Name:BENJAMIN A. CRUNK, DDS, LLC
Entity Type:Organization
Organization Name:BENJAMIN A. CRUNK, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:CRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:205-665-2031
Mailing Address - Street 1:980 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVALLO
Mailing Address - State:AL
Mailing Address - Zip Code:35115-3846
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:35115-3846
Practice Address - Country:US
Practice Address - Phone:205-665-2031
Practice Address - Fax:205-665-5560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL40041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-03995OtherBC/BS OF AL PROVIDER #
AL#05152Medicare UPIN