Provider Demographics
NPI:1598857823
Name:CRUMMEY, WILLIAM KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KEITH
Last Name:CRUMMEY
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 1:6257 TALL PINES DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516
Mailing Address - Country:US
Mailing Address - Phone:912-285-9740
Mailing Address - Fax:
Practice Address - Street 1:1601-B ALICE ST.
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-285-5967
Practice Address - Fax:912-285-0762
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10,0171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA19NCBHDMedicare ID - Type UnspecifiedMEDICARE
GAU25480Medicare UPIN