Healthcare Provider Details

I. General information

NPI: 1578695631
Provider Name (Legal Business Name): MICHAEL G CRALL DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 MAIN ST
CEDAR FALLS IA
50613-4147
US

IV. Provider business mailing address

1504 MAIN ST
CEDAR FALLS IA
50613-4147
US

V. Phone/Fax

Practice location:
  • Phone: 319-266-4029
  • Fax: 707-313-7932
Mailing address:
  • Phone: 319-266-4029
  • Fax: 707-313-7932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number07061
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0063438
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: