Provider Demographics
NPI:1114192838
Name:CRESCENZO, JASON RALPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RALPH
Last Name:CRESCENZO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16345 HARLEM AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2589
Mailing Address - Country:US
Mailing Address - Phone:708-781-9754
Mailing Address - Fax:708-781-9758
Practice Address - Street 1:16345 HARLEM AVE STE 160
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2589
Practice Address - Country:US
Practice Address - Phone:708-781-9754
Practice Address - Fax:708-781-9758
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190275701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice