Provider Demographics
NPI:1477010213
Name:JOSEPH, CRISMON
Entity Type:Individual
Prefix:MR
First Name:CRISMON
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14500 34TH AVE N APT 208
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5215
Mailing Address - Country:US
Mailing Address - Phone:405-326-2827
Mailing Address - Fax:
Practice Address - Street 1:903 W CENTER ST STE 130
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-6278
Practice Address - Country:US
Practice Address - Phone:507-529-0436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH10624124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist