Provider Demographics
NPI:1174629794
Name:CRAWFORD, RICHARD W (DMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:CRAWFORD
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 1:440 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-774-2611
Mailing Address - Fax:207-774-2613
Practice Address - Street 1:440 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-774-2611
Practice Address - Fax:207-774-2613
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME34281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME304020099Medicaid
ME304020099Medicaid
MEMM4854Medicare PIN
U41690Medicare UPIN