Provider Demographics
NPI:1881906634
Name:CALDWELL, CRATISA LATWANN (DDS)
Entity type:Individual
Prefix:DR
First Name:CRATISA
Middle Name:LATWANN
Last Name:CALDWELL
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 1:3952 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2714
Mailing Address - Country:US
Mailing Address - Phone:317-956-0551
Mailing Address - Fax:
Practice Address - Street 1:8151 E 21ST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219
Practice Address - Country:US
Practice Address - Phone:317-353-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60881223D0001X
IN12011470A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1940801Medicaid