Healthcare Provider Details

I. General information

NPI: 1417243874
Provider Name (Legal Business Name): WESLEY DENNIS CROCKETT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 S WHITE MOUNTAIN RD
SHOW LOW AZ
85901-7106
US

IV. Provider business mailing address

7515 SE TUALATIN VALLEY HWY
HILLSBORO OR
97123-8252
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-3937
  • Fax:
Mailing address:
  • Phone: 503-649-7566
  • Fax: 503-649-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3397ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: