Healthcare Provider Details

I. General information

NPI: 1740288844
Provider Name (Legal Business Name): CHARLES HARMON CRAWFORD JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1236 EBENEZER RD STE 110
ROCK HILL SC
29732-2300
US

IV. Provider business mailing address

1236 EBENEZER RD STE 110
ROCK HILL SC
29732-2300
US

V. Phone/Fax

Practice location:
  • Phone: 803-324-7540
  • Fax: 803-324-4128
Mailing address:
  • Phone: 803-324-7540
  • Fax: 803-324-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0255
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: