Provider Demographics
NPI:1174197149
Name:DINGLE, CRAIG W
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:W
Last Name:DINGLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-2421
Mailing Address - Country:US
Mailing Address - Phone:856-451-3727
Mailing Address - Fax:856-455-9706
Practice Address - Street 1:70 W BROAD ST
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2421
Practice Address - Country:US
Practice Address - Phone:856-451-3727
Practice Address - Fax:856-455-9706
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000324175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ031164Medicaid