Provider Demographics
NPI:1679737324
Name:CRAVENS, LINDA CAROLE (RDN)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:CAROLE
Last Name:CRAVENS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645
Mailing Address - Country:US
Mailing Address - Phone:573-783-4100
Mailing Address - Fax:573-783-2940
Practice Address - Street 1:731 W MAIN ST
Practice Address - Street 2:GUY A WALKER DDS
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645
Practice Address - Country:US
Practice Address - Phone:573-783-4100
Practice Address - Fax:573-783-2940
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000563122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO749312104Medicaid