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General NPI Number Information
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NPI Number | 1053617746
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Entity Type | Organization
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Legal Business Name | CRAWFORDSVILLE ORAL SURGERY
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Dates
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Enumeration Date | 01/28/2011
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Last Update Date | 01/28/2011
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Provider Practice Location Address
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Address Line | 408 W MARKET ST
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City | CRAWFORDSVILLE
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State | IN
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Zip | 47933-1600
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Country | US
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Telephone | 765-807-0230
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Fax |
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Provider Business Mailing Address
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Address Line | 408 W MARKET ST
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City | CRAWFORDSVILLE
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State | IN
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Zip | 47933-1600
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Country | US
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Telephone | 765-807-0230
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRETT HENRIKSON
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Credential | DDS
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Telephone | 765-807-0230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 1201055A
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License Number State | IN
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