Provider Demographics
NPI:1164508743
Name:CROUCH, KEITH ALLEN (DDS)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALLEN
Last Name:CROUCH
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 1:511 BROOKDALE DRIVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4107
Mailing Address - Country:US
Mailing Address - Phone:704-873-9641
Mailing Address - Fax:704-873-1544
Practice Address - Street 1:511 BROOKDALE DRIVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-873-9641
Practice Address - Fax:704-873-1544
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991922Medicaid