MEDICARE: DR. LYNETTE S CROCKER DDS

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	1223G0001X	General Practice Dentistry	6727	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275628653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYNETTE S CROCKER DDS

Provider Business Mailing Address
First Line	:	6104 FAYETTEVILLE ROAD
Second Line	:	SUITE 104
City	:	DURHAM
State	:	NC
Zip	:	27713-6283
Country	:	US
Telephone Number	:	919-544-6727
Fax Number	:	919-484-1434

Provider Business Practice Location Address
First Line	:	6104 FAYETTEVILLE ROAD
Second Line	:	SUITE 104
City	:	DURHAM
State	:	NC
Zip	:	27713-6283
Country	:	US
Telephone Number	:	919-544-6727
Fax Number	:	919-484-1434

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	11/19/2013

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