Provider Demographics
NPI:1740518018
Name:FERGUSON, CRYSTAL D (DDS)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7863 BROADWAY
Mailing Address - Street 2:SUITE 111
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5553
Mailing Address - Country:US
Mailing Address - Phone:219-769-6636
Mailing Address - Fax:219-769-4396
Practice Address - Street 1:7863 BROADWAY
Practice Address - Street 2:SUITE 111
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5553
Practice Address - Country:US
Practice Address - Phone:219-769-6636
Practice Address - Fax:219-769-4396
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011366A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry