Provider Demographics
NPI:1376661116
Name:CRUTCHER, MICHELLE (RDH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-1331
Mailing Address - Country:US
Mailing Address - Phone:847-546-2900
Mailing Address - Fax:847-546-6603
Practice Address - Street 1:305 E ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-1331
Practice Address - Country:US
Practice Address - Phone:847-546-2900
Practice Address - Fax:847-546-6603
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist