Provider Demographics
NPI:1104024660
Name:CRANDALL, JAMES BERRETT (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BERRETT
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7484 UNIVERSITY AVENUE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6084
Mailing Address - Country:US
Mailing Address - Phone:619-460-2500
Mailing Address - Fax:619-462-3169
Practice Address - Street 1:7484 UNIVERSITY AVENUE
Practice Address - Street 2:SUITE 150
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-6084
Practice Address - Country:US
Practice Address - Phone:619-460-2500
Practice Address - Fax:619-462-3169
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24760122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2476001Medicaid