Healthcare Provider Details

I. General information

NPI: 1609870070
Provider Name (Legal Business Name): W DALE CRUM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 E 29TH AVE STE 104
SPOKANE WA
99203-3961
US

IV. Provider business mailing address

2204 E 29TH AVE STE 104
SPOKANE WA
99203-3961
US

V. Phone/Fax

Practice location:
  • Phone: 509-928-8800
  • Fax: 509-321-0154
Mailing address:
  • Phone: 509-928-8800
  • Fax: 509-321-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7006
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: