Healthcare Provider Details

I. General information

NPI: 1740492081
Provider Name (Legal Business Name): DR. LARRY B. CRAWFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2007
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E ALESSANDRO BLVD STE 3B
RIVERSIDE CA
92508-2464
US

IV. Provider business mailing address

301 E ALESSANDRO BLVD STE 3B
RIVERSIDE CA
92508-2464
US

V. Phone/Fax

Practice location:
  • Phone: 951-789-1888
  • Fax: 951-789-8878
Mailing address:
  • Phone: 951-789-1888
  • Fax: 951-789-8878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number32639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: