Provider Demographics
NPI:1538331350
Name:DR ROSLYN M. CRISP
Entity Type:Organization
Organization Name:DR ROSLYN M. CRISP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-228-8392
Mailing Address - Street 1:1203 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2846
Mailing Address - Country:US
Mailing Address - Phone:336-228-8392
Mailing Address - Fax:336-227-0635
Practice Address - Street 1:1203 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2846
Practice Address - Country:US
Practice Address - Phone:336-228-8392
Practice Address - Fax:336-227-0635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14816OtherDORAL DENTAL
VA14816Medicaid
NC8991896Medicaid