Provider Demographics
NPI:1568895613
Name:CLINTON CRAWFORD DDS LLC
Entity Type:Organization
Organization Name:CLINTON CRAWFORD DDS LLC
Other - Org Name:FENTON FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYIAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:240-839-5100
Mailing Address - Street 1:8913 WOODYARD RD
Mailing Address - Street 2:B
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4257
Mailing Address - Country:US
Mailing Address - Phone:301-363-2336
Mailing Address - Fax:301-363-2317
Practice Address - Street 1:8913 WOODYARD RD
Practice Address - Street 2:B
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-4257
Practice Address - Country:US
Practice Address - Phone:301-363-2336
Practice Address - Fax:301-363-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty