Provider Demographics
NPI:1225182942
Name:CROCKER, STEPHEN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DAVID
Last Name:CROCKER
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 1:18518 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3232
Mailing Address - Country:US
Mailing Address - Phone:248-473-0050
Mailing Address - Fax:248-473-7490
Practice Address - Street 1:18518 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3232
Practice Address - Country:US
Practice Address - Phone:248-473-0050
Practice Address - Fax:248-473-7490
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010093211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice