Provider Demographics
NPI:1336298447
Name:CRESPO, LUIS IGNACIO (DDS)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:IGNACIO
Last Name:CRESPO
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 1:1811 E INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-6030
Mailing Address - Country:US
Mailing Address - Phone:704-216-8777
Mailing Address - Fax:704-638-3129
Practice Address - Street 1:1811 E INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146-6030
Practice Address - Country:US
Practice Address - Phone:704-216-8777
Practice Address - Fax:704-638-3129
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7121122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899013WMedicaid