Provider Demographics
NPI:1194839373
Name:CRAWFORD, GREGORY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:CRAWFORD
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 1:4116 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6911
Mailing Address - Country:US
Mailing Address - Phone:260-482-3759
Mailing Address - Fax:260-482-3750
Practice Address - Street 1:4116 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6911
Practice Address - Country:US
Practice Address - Phone:260-482-3759
Practice Address - Fax:260-482-3750
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006931A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100050850AMedicaid