=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851529705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD CREW CARRIS DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2009
-----------------------------------------------------
Last Update Date | 11/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 SE 192ND AVE STE 100
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-9679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-604-5873
-----------------------------------------------------
Fax | 360-604-5867
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 322 SE 192ND AVE STE 100
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-9679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-604-5873
-----------------------------------------------------
Fax | 360-604-5867
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE60249401
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------