Provider Demographics
NPI:1720012503
Name:CRAWFORD, JONATHAN G (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:G
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 N YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7806
Mailing Address - Country:US
Mailing Address - Phone:509-783-7600
Mailing Address - Fax:509-783-0774
Practice Address - Street 1:512 N YOUNG ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7806
Practice Address - Country:US
Practice Address - Phone:509-783-7600
Practice Address - Fax:509-783-0774
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA64591223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5017660Medicaid
WAU50124Medicare UPIN
WA319200902Medicare ID - Type Unspecified