Healthcare Provider Details

I. General information

NPI: 1356563449
Provider Name (Legal Business Name): JOHN ROBERT CRAWFORD DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7851 COOPER RD
KENOSHA WI
53142-4181
US

IV. Provider business mailing address

7851 COOPER RD
KENOSHA WI
53142-4181
US

V. Phone/Fax

Practice location:
  • Phone: 262-694-5272
  • Fax: 262-694-3121
Mailing address:
  • Phone: 262-694-5272
  • Fax: 262-694-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2969-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: