MEDICARE: DR. MARIKO CROCKER DDS

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	122300000X	Dentist	10516	TN
2	1223G0001X	General Practice Dentistry	10516	TN

General Provider Information

NPI Number	:	1538681713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIKO CROCKER DDS

Provider Business Mailing Address
First Line	:	402 S GAY ST STE 407
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37902-1166
Country	:	US
Telephone Number	:	865-809-9118
Fax Number	:

Provider Business Practice Location Address
First Line	:	2719 KINGSTON PIKE
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37919-4620
Country	:	US
Telephone Number	:	865-973-9899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2017
Last Update Date	:	07/10/2017

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