Healthcare Provider Details

I. General information

NPI: 1285684795
Provider Name (Legal Business Name): DAVID L CROUCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8012 112TH STREET CT E
PUYALLUP WA
98373-7856
US

IV. Provider business mailing address

8012 112TH STREET CT E
PUYALLUP WA
98373-7856
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-9591
  • Fax: 253-848-3777
Mailing address:
  • Phone: 253-848-9591
  • Fax: 253-848-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE00005165
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: