Provider Demographics
NPI:1952422651
Name:CRISHAM, JOSEPH MARTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MARTIN
Last Name:CRISHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 EAST EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2140
Mailing Address - Country:US
Mailing Address - Phone:815-284-6676
Mailing Address - Fax:815-284-8667
Practice Address - Street 1:122 EAST EVERETT ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-284-6676
Practice Address - Fax:815-284-8667
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics