Provider Demographics
NPI:1538681713
Name:CROCKER, MARIKO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIKO
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARIKO
Other - Middle Name:CROCKER
Other - Last Name:MCCALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:402 S GAY ST STE 407
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37902-1166
Mailing Address - Country:US
Mailing Address - Phone:865-809-9118
Mailing Address - Fax:
Practice Address - Street 1:2719 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4620
Practice Address - Country:US
Practice Address - Phone:865-973-9899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10516122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist