Provider Demographics
NPI:1821096058
Name:MCCROSKEY, JOHN B (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:MCCROSKEY
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 1:12625 SW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8306
Mailing Address - Country:US
Mailing Address - Phone:503-968-9766
Mailing Address - Fax:503-968-9768
Practice Address - Street 1:12625 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8306
Practice Address - Country:US
Practice Address - Phone:503-968-9766
Practice Address - Fax:503-968-9768
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD65411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice