Provider Demographics
NPI:1366468530
Name:DAVID S. CROCKETT DDS INC
Entity Type:Organization
Organization Name:DAVID S. CROCKETT DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SANDERS
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-581-1122
Mailing Address - Street 1:22296 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4005
Mailing Address - Country:US
Mailing Address - Phone:510-581-1122
Mailing Address - Fax:510-581-1043
Practice Address - Street 1:22296 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4005
Practice Address - Country:US
Practice Address - Phone:510-581-1122
Practice Address - Fax:510-581-1043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA269771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB26977OtherMEDICAL