Provider Demographics
NPI:1417126244
Name:CROFT, GORDON G (DMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:G
Last Name:CROFT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-467-3391
Practice Address - Street 1:8300 NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7132
Practice Address - Country:US
Practice Address - Phone:208-377-8078
Practice Address - Fax:208-377-3689
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD15181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6C396OtherBLUE CROSS
ID000789200Medicaid
ID462879OtherUNITED CONCORDIA