Provider Demographics
NPI:1720297344
Name:ST.ELMO W. CRAWFORD D.D.S.P.C.
Entity Type:Organization
Organization Name:ST.ELMO W. CRAWFORD D.D.S.P.C.
Other - Org Name:CONNECTICUT AVENUE DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ST.ELMO
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-399-2244
Mailing Address - Street 1:1922 BENNING RD NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4724
Mailing Address - Country:US
Mailing Address - Phone:202-399-2244
Mailing Address - Fax:202-399-7800
Practice Address - Street 1:1922 BENNING RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4724
Practice Address - Country:US
Practice Address - Phone:202-399-2244
Practice Address - Fax:202-388-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN32721223G0001X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035217400Medicaid
DC016851500Medicaid