Healthcare Provider Details

I. General information

NPI: 1063597375
Provider Name (Legal Business Name): JOHN MAX CRESTETTO DDS,MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N WINSTEAD AVE SUITE 130
ROCKY MOUNT NC
27804-8467
US

IV. Provider business mailing address

901 N WINSTEAD AVE SUITE 130
ROCKY MOUNT NC
27804-8467
US

V. Phone/Fax

Practice location:
  • Phone: 252-443-7331
  • Fax: 252-937-2381
Mailing address:
  • Phone: 252-443-7331
  • Fax: 252-937-2381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6759
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: