Provider Demographics
NPI:1417237363
Name:CROUCH, EVERETT CORNISH JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:EVERETT
Middle Name:CORNISH
Last Name:CROUCH
Suffix:JR
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 1:6073 SAN JOSE WEST
Mailing Address - Street 2:DR E C CROUCH
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214
Mailing Address - Country:US
Mailing Address - Phone:904-737-2111
Mailing Address - Fax:904-737-2207
Practice Address - Street 1:6073 SAN JOSE BLVD, WEST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217
Practice Address - Country:US
Practice Address - Phone:904-737-2111
Practice Address - Fax:907-737-2207
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3080122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist