Healthcare Provider Details

I. General information

NPI: 1457560815
Provider Name (Legal Business Name): TODD JAMES CROCKETT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHEYENNE AVE.
LAME DEER MT
59043
US

IV. Provider business mailing address

PO BOX 2409
COLSTRIP MT
59323-2409
US

V. Phone/Fax

Practice location:
  • Phone: 406-477-4509
  • Fax:
Mailing address:
  • Phone: 406-740-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2006021224
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: