Healthcare Provider Details

I. General information

NPI: 1982604153
Provider Name (Legal Business Name): MICHAEL THOMAS CRUM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VERA AVE
RIPON CA
95366-2345
US

IV. Provider business mailing address

200 VERA AVE
RIPON CA
95366-2345
US

V. Phone/Fax

Practice location:
  • Phone: 209-599-4239
  • Fax: 209-599-7899
Mailing address:
  • Phone: 209-599-4239
  • Fax: 209-599-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number29032
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: