MEDICARE: DR. JERE WALTON CRENSHAW D.D.S.,M.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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DS 2617	TN

General Provider Information

NPI Number	:	1861496317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERE WALTON CRENSHAW D.D.S.,M.S.

Provider Business Mailing Address
First Line	:	1623 E REELFOOT AVE
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-6031
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1623 E REELFOOT AVE
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-6031
Country	:	US
Telephone Number	:	731-885-7661
Fax Number	:

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	09/10/2007

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