Healthcare Provider Details

I. General information

NPI: 1417475716
Provider Name (Legal Business Name): MICHAEL G. CROOKSTON DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S BINKLEY ST STE A
SOLDOTNA AK
99669-8038
US

IV. Provider business mailing address

4168 N 3750 E
LIBERTY UT
84310-6816
US

V. Phone/Fax

Practice location:
  • Phone: 907-262-8834
  • Fax:
Mailing address:
  • Phone: 801-389-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateAK

VIII. Authorized Official

Name: DR. MICHAEL G CROOKSTON
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 801-389-4597