Provider Demographics
NPI:1730304437
Name:CRAWFORD, BRIAN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROBERT
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 1:921 S. 8TH AVE., STOP 8088
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8088
Mailing Address - Country:US
Mailing Address - Phone:208-282-5275
Mailing Address - Fax:208-282-4950
Practice Address - Street 1:465 MEMORIAL DR.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8088
Practice Address - Country:US
Practice Address - Phone:208-282-5275
Practice Address - Fax:208-282-4950
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37341223G0001X
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8068165Medicaid