Provider Demographics
NPI:1689924367
Name:CROUCH, TIMOTHY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:CROUCH
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 1:511 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4107
Mailing Address - Country:US
Mailing Address - Phone:704-873-9641
Mailing Address - Fax:704-873-1544
Practice Address - Street 1:511 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-873-9641
Practice Address - Fax:704-873-1544
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice