Provider Demographics
NPI:1982963237
Name:DAVIS, CRYSTAL JUJUAN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:JUJUAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43401 N JEFFERSON AVE BLDG 825
Mailing Address - Street 2:SELFRIDGE ANG BASE
Mailing Address - City:SELFRIDGE ANGB
Mailing Address - State:MI
Mailing Address - Zip Code:48045-5266
Mailing Address - Country:US
Mailing Address - Phone:586-239-3005
Mailing Address - Fax:586-239-5010
Practice Address - Street 1:43401 N JEFFERSON AVE BLDG 825
Practice Address - Street 2:SELFRIDGE ANG BASE
Practice Address - City:SELFRIDGE ANGB
Practice Address - State:MI
Practice Address - Zip Code:48045-5266
Practice Address - Country:US
Practice Address - Phone:586-239-3005
Practice Address - Fax:586-239-5010
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902011199124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist