Healthcare Provider Details

I. General information

NPI: 1871541276
Provider Name (Legal Business Name): MICHAEL RAYMOND CRADDOCK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/14/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050A 2ND ST SE
KIRTLAND AFB NM
87117-5901
US

IV. Provider business mailing address

2050A 2ND ST SE
KIRTLAND AFB NM
87117-1823
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3200
  • Fax:
Mailing address:
  • Phone: 719-502-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5009
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14481
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number14481
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDEN.00009325
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00009325
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: