Provider Demographics
NPI:1811437361
Name:CRUTCHFIELD DENTAL GROUP LLC
Entity type:Organization
Organization Name:CRUTCHFIELD DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/ MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUTCHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:513-909-4746
Mailing Address - Street 1:9519 TAHOE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3770
Mailing Address - Country:US
Mailing Address - Phone:937-999-6500
Mailing Address - Fax:
Practice Address - Street 1:8520 LANDEN DR
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039-9565
Practice Address - Country:US
Practice Address - Phone:513-909-4746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0231371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty