Healthcare Provider Details

I. General information

NPI: 1265720320
Provider Name (Legal Business Name): CROWDER FAMILY DENTAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 HIGHWAY 51 S
RIPLEY TN
38063-5598
US

IV. Provider business mailing address

1800 HIGHWAY 51 S
RIPLEY TN
38063-5598
US

V. Phone/Fax

Practice location:
  • Phone: 731-635-5000
  • Fax: 731-635-7540
Mailing address:
  • Phone: 731-635-5000
  • Fax: 731-635-7540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS4048
License Number StateTN

VIII. Authorized Official

Name: DR. ROY CROWDER JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 731-635-5000