Provider Demographics
NPI:1508425026
Name:CROUCH, JORY TYLER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORY
Middle Name:TYLER
Last Name:CROUCH
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 1:13016 ELLISON AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1641
Mailing Address - Country:US
Mailing Address - Phone:308-380-7622
Mailing Address - Fax:
Practice Address - Street 1:2916 W STOLLEY PARK RD STE A
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-6808
Practice Address - Country:US
Practice Address - Phone:308-382-1734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-08
Last Update Date:2019-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7554122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist