MEDICARE: JUSTIN CROCKETT 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	24782	TX

General Provider Information

NPI Number	:	1770879876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN CROCKETT DDS

Provider Business Mailing Address
First Line	:	811 E HEIGHTS HOLLOW LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-7073
Country	:	US
Telephone Number	:	936-443-7366
Fax Number	:

Provider Business Practice Location Address
First Line	:	9778 KATY FWY STE 450
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-6234
Country	:	US
Telephone Number	:	936-443-7366
Fax Number	:

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

Provider Enumeration Date	:	06/27/2011
Last Update Date	:	07/01/2011

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Directions to “ JUSTIN CROCKETT DDS” Practice Location

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