Provider Demographics
NPI:1275628653
Name:CROCKER, LYNETTE S (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYNETTE
Middle Name:S
Last Name:CROCKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 FAYETTEVILLE ROAD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6283
Mailing Address - Country:US
Mailing Address - Phone:919-544-6727
Mailing Address - Fax:919-484-1434
Practice Address - Street 1:6104 FAYETTEVILLE ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6283
Practice Address - Country:US
Practice Address - Phone:919-544-6727
Practice Address - Fax:919-484-1434
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899009VMedicaid