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General NPI Number Information
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NPI Number | 1508425026
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Entity Type | Individual
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Provider Name | JORY TYLER CROUCH DDS
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Gender | Male
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Dates
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Enumeration Date | 06/08/2019
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Last Update Date | 06/08/2019
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Provider Practice Location Address
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Address Line | 2916 W STOLLEY PARK RD STE A
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City | GRAND ISLAND
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State | NE
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Zip | 68801-6808
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Country | US
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Telephone | 308-382-1734
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Fax |
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Provider Business Mailing Address
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Address Line | 13016 ELLISON AVE
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City | OMAHA
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State | NE
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Zip | 68164-1641
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Country | US
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Telephone | 308-380-7622
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7554
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License Number State | NE
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