MEDICARE: DR. JEFFREY GALE CRENSHAW DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	7853	KY
2	122300000X	Dentist	7853	KY

General Provider Information

NPI Number	:	1154304277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY GALE CRENSHAW DMD

Provider Business Mailing Address
First Line	:	12927 W HIGHWAY 42
Second Line	:
City	:	PROSPECT
State	:	KY
Zip	:	40059-9107
Country	:	US
Telephone Number	:	502-292-1160
Fax Number	:	502-292-1194

Provider Business Practice Location Address
First Line	:	12927 W HIGHWAY 42
Second Line	:
City	:	PROSPECT
State	:	KY
Zip	:	40059-9107
Country	:	US
Telephone Number	:	502-292-1160
Fax Number	:	502-292-1194

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	06/08/2011

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