Provider Demographics
NPI:1235456153
Name:MICHELLE C. CROCKER, DMD, PC
Entity Type:Organization
Organization Name:MICHELLE C. CROCKER, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-515-6092
Mailing Address - Street 1:13195 SW SHORE DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1683
Mailing Address - Country:US
Mailing Address - Phone:503-641-3550
Mailing Address - Fax:
Practice Address - Street 1:11786 SW BARNES RD STE 320
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5930
Practice Address - Country:US
Practice Address - Phone:503-641-3550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-02
Last Update Date:2010-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8443122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty