Provider Demographics
NPI:1356362800
Name:CROCKETT, DENNIS M (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26726 CROWN VALLEY PKWY.
Mailing Address - Street 2:SUITE 200 HEAD & NECK ASSOCIATES OF ORANGE COUNTY
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:949-364-4361
Mailing Address - Fax:949-364-4495
Practice Address - Street 1:26726 CROWN VALLEY PKWY.
Practice Address - Street 2:SUITE 200 HEAD & NECK ASSOCIATES OF ORANGE COUNTY
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-4361
Practice Address - Fax:949-364-4495
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42104207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
W8109OtherGEL PTAN
CA00G421040Medicaid
CAWG42104CMedicare ID - Type Unspecified
CA00G421040Medicaid
A02735Medicare UPIN
W8109OtherGEL PTAN