Provider Demographics
NPI:1417475716
Name:MICHAEL G. CROOKSTON DDS PC
Entity Type:Organization
Organization Name:MICHAEL G. CROOKSTON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:CROOKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-389-4597
Mailing Address - Street 1:4168 N 3750 E
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:UT
Mailing Address - Zip Code:84310-6816
Mailing Address - Country:US
Mailing Address - Phone:801-389-4597
Mailing Address - Fax:
Practice Address - Street 1:104 S BINKLEY ST STE A
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8038
Practice Address - Country:US
Practice Address - Phone:907-262-8834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental