=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861518045
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW EARL CROW D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 508A VINCENT ST
-----------------------------------------------------
City | STEVENS POINT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54481-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-344-6390
-----------------------------------------------------
Fax | 715-344-9888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 508A VINCENT ST
-----------------------------------------------------
City | STEVENS POINT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54481-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-344-6390
-----------------------------------------------------
Fax | 715-344-9888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5607-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------