Provider Demographics
NPI:1851569719
Name:CRESCENT DENTAL, LLC
Entity Type:Organization
Organization Name:CRESCENT DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SYAMACK
Authorized Official - Middle Name:
Authorized Official - Last Name:GANJAVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-230-0000
Mailing Address - Street 1:120 TALLEYRAND DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-3948
Mailing Address - Country:US
Mailing Address - Phone:302-230-0000
Mailing Address - Fax:
Practice Address - Street 1:129 S. WEST ST.
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801
Practice Address - Country:US
Practice Address - Phone:302-230-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG10001184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty