Healthcare Provider Details

I. General information

NPI: 1386167377
Provider Name (Legal Business Name): CREIGH CRANDALL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 HIGH ST STE A
WALDORF MD
20602-2191
US

IV. Provider business mailing address

83 HIGH ST STE A
WALDORF MD
20602-2191
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-3601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13894
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00205436
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number18432
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: