Provider Demographics
NPI:1851454870
Name:MICHAEL D CRAWFORD DDS INC
Entity Type:Organization
Organization Name:MICHAEL D CRAWFORD DDS INC
Other - Org Name:CRAWFORD DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-262-0706
Mailing Address - Street 1:PO BOX 13646
Mailing Address - Street 2:5060 LOGAN AVE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113
Mailing Address - Country:US
Mailing Address - Phone:619-262-0706
Mailing Address - Fax:619-262-4207
Practice Address - Street 1:5060 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113
Practice Address - Country:US
Practice Address - Phone:619-262-0706
Practice Address - Fax:619-262-4207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23815122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9224701Medicaid
CAB2381501OtherDELTA DENTAL HEALTHY FAMI