Provider Demographics
NPI:1013327618
Name:MCCRACKEN, DAVID EVAN (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EVAN
Last Name:MCCRACKEN
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 1:710 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-3352
Mailing Address - Country:US
Mailing Address - Phone:208-240-5249
Mailing Address - Fax:
Practice Address - Street 1:710 MAIN ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-3352
Practice Address - Country:US
Practice Address - Phone:208-240-5249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTDEN-DEN-LIC-9639122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist