=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518217975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. KEITH A. CROUCH DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2012
-----------------------------------------------------
Last Update Date | 09/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 BROOKDALE DR
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-873-9641
-----------------------------------------------------
Fax | 704-873-1544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 511 BROOKDALE DR
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-873-9641
-----------------------------------------------------
Fax | 704-873-1544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KEITH A. CROUCH
-----------------------------------------------------
Credential | DDS PA
-----------------------------------------------------
Telephone | 704-873-9641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5075
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------