Provider Demographics
NPI:1801980511
Name:CROOKER, KELLY (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:CROOKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:251-690-8158
Mailing Address - Fax:251-544-2188
Practice Address - Street 1:950 W COY SMITH HWY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:AL
Practice Address - Zip Code:36560-3201
Practice Address - Country:US
Practice Address - Phone:251-829-9884
Practice Address - Fax:251-829-9507
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL56531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL011846OtherMEDICARE GROUP NUMBER
AL1063439065OtherSITE NPI GROUP NUMBER
AL630000013Medicaid