Provider Demographics
NPI:1164601738
Name:CROCKETT, BENJAMIN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:CROCKETT
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 1:6360 US HIGHWAY 93 S
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-8235
Mailing Address - Country:US
Mailing Address - Phone:406-892-2104
Mailing Address - Fax:406-892-1422
Practice Address - Street 1:6360 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-8235
Practice Address - Country:US
Practice Address - Phone:406-892-2104
Practice Address - Fax:406-892-1422
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25803122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist