Provider Demographics
NPI:1356367502
Name:CROCKETT, DAVID SANDERS (DDS)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:SANDERS
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22296 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541
Mailing Address - Country:US
Mailing Address - Phone:510-581-1122
Mailing Address - Fax:510-581-1043
Practice Address - Street 1:22296 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541
Practice Address - Country:US
Practice Address - Phone:510-581-1122
Practice Address - Fax:510-581-1043
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA269771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB26977OtherMEDICAL