Provider Demographics
NPI:1932344702
Name:WL CRABTREE GENERAL DENTISTRY
Entity Type:Organization
Organization Name:WL CRABTREE GENERAL DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:L
Authorized Official - Last Name:CRABTREE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-236-3125
Mailing Address - Street 1:221 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4327
Mailing Address - Country:US
Mailing Address - Phone:870-236-3125
Mailing Address - Fax:870-236-3125
Practice Address - Street 1:221 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4327
Practice Address - Country:US
Practice Address - Phone:870-236-3125
Practice Address - Fax:870-236-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102519608Medicaid