Provider Demographics
NPI:1790707818
Name:CROMWELL, ANDREW CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CLARK
Last Name:CROMWELL
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 1:315 OAK ST
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-2338
Mailing Address - Country:US
Mailing Address - Phone:406-563-3025
Mailing Address - Fax:
Practice Address - Street 1:315 OAK ST
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2338
Practice Address - Country:US
Practice Address - Phone:406-563-3025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT21191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0113204Medicaid