Provider Demographics
NPI:1851952501
Name:CRANE, RUSSELL JARED (DMD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JARED
Last Name:CRANE
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 1:6233 W BEHREND DR APT 2064
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6929
Mailing Address - Country:US
Mailing Address - Phone:208-358-0299
Mailing Address - Fax:
Practice Address - Street 1:35004 N NORTH VALLEY PKWY STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-3255
Practice Address - Country:US
Practice Address - Phone:623-879-9503
Practice Address - Fax:623-587-6453
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010401122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist