Provider Demographics
NPI:1083805386
Name:RODDIE A CROUCH DDS PC
Entity Type:Organization
Organization Name:RODDIE A CROUCH DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RODDIE
Authorized Official - Middle Name:AMOS
Authorized Official - Last Name:CROUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-977-9090
Mailing Address - Street 1:2125 POST OAK TRITT ROAD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1609
Mailing Address - Country:US
Mailing Address - Phone:770-977-9090
Mailing Address - Fax:770-578-8289
Practice Address - Street 1:2125 POST OAK TRITT ROAD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-1609
Practice Address - Country:US
Practice Address - Phone:770-977-9090
Practice Address - Fax:770-578-8289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty