Provider Demographics
NPI:1275556409
Name:WILLIAM KEITH CRUMMEY DMD PC
Entity Type:Organization
Organization Name:WILLIAM KEITH CRUMMEY DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PRESIDENT OF CORP.
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CRUMMEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PC
Authorized Official - Phone:912-285-5967
Mailing Address - Street 1:1601 ALICE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4532
Mailing Address - Country:US
Mailing Address - Phone:912-285-5967
Mailing Address - Fax:912-285-0762
Practice Address - Street 1:1601 ALICE ST
Practice Address - Street 2:SUITE B
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4532
Practice Address - Country:US
Practice Address - Phone:912-285-5967
Practice Address - Fax:912-285-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10017OtherLIC#
GA10017OtherLIC#
GA10017OtherLIC#
GAU25480Medicare UPIN