Healthcare Provider Details

I. General information

NPI: 1245293869
Provider Name (Legal Business Name): KENNETH OWEN CROSBY II D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6079 N FRESNO ST STE 105
FRESNO CA
93710-5276
US

IV. Provider business mailing address

6079 N FRESNO ST STE 105
FRESNO CA
93710-5276
US

V. Phone/Fax

Practice location:
  • Phone: 559-222-7001
  • Fax: 559-222-7087
Mailing address:
  • Phone: 559-222-7001
  • Fax: 559-222-7087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33447
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number33447
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: