MEDICARE: LARRY W. CROCKER DMD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1215034608
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARRY W. CROCKER DMD, PC

Provider Business Mailing Address
First Line	:	1317 D' ADRIAN PROFESSIONAL PARK
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035
Country	:	US
Telephone Number	:	618-466-0733
Fax Number	:	618-466-1433

Provider Business Practice Location Address
First Line	:	1317 DADRIAN PROFESSIONAL PARK
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-1686
Country	:	US
Telephone Number	:	618-466-0733
Fax Number	:	618-466-1433

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LARRY PRUETT
Credential	:
Telephone Number	:	618-466-0733

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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