Provider Demographics
NPI:1487661963
Name:CROCKER, CHARLES L (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:CROCKER
Suffix:
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 1:952 W MAHAN DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344
Mailing Address - Country:US
Mailing Address - Phone:850-997-3984
Mailing Address - Fax:
Practice Address - Street 1:952 MAHAN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-1136
Practice Address - Country:US
Practice Address - Phone:850-997-3984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 72291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice