Provider Demographics
NPI:1588617518
Name:CROCKER, LARRY WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WAYNE
Last Name:CROCKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 DADRIAN PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1686
Mailing Address - Country:US
Mailing Address - Phone:618-466-0733
Mailing Address - Fax:618-466-1433
Practice Address - Street 1:1317 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1686
Practice Address - Country:US
Practice Address - Phone:618-466-0733
Practice Address - Fax:618-466-1433
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice