Provider Demographics
NPI:1275790735
Name:CROCO ORTHODONTICS P.L.C.
Entity Type:Organization
Organization Name:CROCO ORTHODONTICS P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:AT
Authorized Official - Last Name:CROCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:319-545-7600
Mailing Address - Street 1:2451 CORAL CT STE 2
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2837
Mailing Address - Country:US
Mailing Address - Phone:319-545-7600
Mailing Address - Fax:319-545-7640
Practice Address - Street 1:2451 CORAL CT STE 2
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2837
Practice Address - Country:US
Practice Address - Phone:319-545-7600
Practice Address - Fax:319-545-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0463018Medicaid