Provider Demographics
NPI:1750646899
Name:CRANDALL, CLINTON R (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:R
Last Name:CRANDALL
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 1:605 S. COOLIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1863
Mailing Address - Country:US
Mailing Address - Phone:509-765-0674
Mailing Address - Fax:509-765-6591
Practice Address - Street 1:1450 FIRST AVENUE SW
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:WA
Practice Address - Zip Code:98848
Practice Address - Country:US
Practice Address - Phone:509-765-0674
Practice Address - Fax:509-765-6591
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-04
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602908981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice