Healthcare Provider Details

I. General information

NPI: 1780255539
Provider Name (Legal Business Name): LILY BARBOSA CROCCO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

358 FRONT AVE NW
CASTLE ROCK WA
98611-8996
US

IV. Provider business mailing address

140 GRAND RIDGE RD
TOUTLE WA
98649-4200
US

V. Phone/Fax

Practice location:
  • Phone: 360-274-9100
  • Fax:
Mailing address:
  • Phone: 360-274-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDENT.DE.61580977
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: