Provider Demographics
NPI:1407217664
Name:CROCKETT DENTAL CARE PLLC
Entity Type:Organization
Organization Name:CROCKETT DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:HENDERSON
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:936-544-3554
Mailing Address - Street 1:1050 E LOOP 304 STE 120
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-1800
Mailing Address - Country:US
Mailing Address - Phone:936-544-3554
Mailing Address - Fax:
Practice Address - Street 1:1050 E LOOP 304 STE 120
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1800
Practice Address - Country:US
Practice Address - Phone:936-544-3554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8092122300000X
TX17145122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1942318035OtherHUMANA
TX1598873614OtherHUMANA