Healthcare Provider Details

I. General information

NPI: 1497732861
Provider Name (Legal Business Name): JOHN WALTON CROWDER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 MURRAY GUARD DR
JACKSON TN
38305-3610
US

IV. Provider business mailing address

39 MURRAY GUARD DR
JACKSON TN
38305-3610
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-7799
  • Fax:
Mailing address:
  • Phone: 731-660-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS 4312
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: