Healthcare Provider Details

I. General information

NPI: 1164601738
Provider Name (Legal Business Name): BENJAMIN DAVID CROCKETT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 US HIGHWAY 93 S
WHITEFISH MT
59937-8235
US

IV. Provider business mailing address

6360 US HIGHWAY 93 S
WHITEFISH MT
59937-8235
US

V. Phone/Fax

Practice location:
  • Phone: 406-892-2104
  • Fax: 406-892-1422
Mailing address:
  • Phone: 406-892-2104
  • Fax: 406-892-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number25803
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: