Provider Demographics
NPI:1851529705
Name:CARRIS, TODD CREW (DMD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:CREW
Last Name:CARRIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 SE 192ND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9679
Mailing Address - Country:US
Mailing Address - Phone:360-604-5873
Mailing Address - Fax:360-604-5867
Practice Address - Street 1:322 SE 192ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9679
Practice Address - Country:US
Practice Address - Phone:360-604-5873
Practice Address - Fax:360-604-5867
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602494011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice