=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417475716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL G. CROOKSTON DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2017
-----------------------------------------------------
Last Update Date | 04/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 S BINKLEY ST STE A
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-8038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-262-8834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4168 N 3750 E
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84310-6816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-389-4597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL G CROOKSTON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 801-389-4597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------