Provider Demographics
NPI:1497323976
Name:CRAWFORD, DERRICK MYRON (DDS, MS)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:MYRON
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 SW LATOUR PEAK ST
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5287
Mailing Address - Country:US
Mailing Address - Phone:626-260-0729
Mailing Address - Fax:
Practice Address - Street 1:505 S MOUNTAIN VIEW RD
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-9205
Practice Address - Country:US
Practice Address - Phone:208-882-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611575271223X0400X
IDD-52651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics