Provider Demographics
NPI:1700456605
Name:CROFTS, RUSTY JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSTY
Middle Name:
Last Name:CROFTS
Suffix:JR
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 1:511 SW 10TH AVE STE 704
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE STE 704
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2708
Practice Address - Country:US
Practice Address - Phone:503-227-2883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11625122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist