MEDICARE: DR. WILLIE CRADOC III D.D.S.

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	26286	TX

General Provider Information

NPI Number	:	1780983957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIE CRADOC III D.D.S.

Provider Business Mailing Address
First Line	:	2272 LAKE TERRACE DR
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-1763
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5614 W GRAND PKWY S
Second Line	:	SUITE 120
City	:	RICHMOND
State	:	TX
Zip	:	77406-5820
Country	:	US
Telephone Number	:	310-909-3870
Fax Number	:

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

Provider Enumeration Date	:	03/26/2011
Last Update Date	:	03/26/2011

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