Healthcare Provider Details

I. General information

NPI: 1821574708
Provider Name (Legal Business Name): BENJAMIN CROCKETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 S COLUMBIA ST
CHAPEL HILL NC
27599-0001
US

IV. Provider business mailing address

4607 S NEPAL WAY
AURORA CO
80015-5567
US

V. Phone/Fax

Practice location:
  • Phone: 919-537-3737
  • Fax:
Mailing address:
  • Phone: 949-322-7697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number51203
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: