MEDICARE: CROWLEY FAMILY DENTAL CENTER

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	302F00000X	Exclusive Provider Organization	20899	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1235351495	OTHER	TX	DELTA DENTAL
2	1801093844	OTHER	TX	DELTA DENTAL
3	1447431523	OTHER	TX	DELTA DENTAL

General Provider Information

NPI Number	:	1922423078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWLEY FAMILY DENTAL CENTER

Provider Business Mailing Address
First Line	:	779 FM 1187 E
Second Line	:
City	:	CROWLEY
State	:	TX
Zip	:	76036-4346
Country	:	US
Telephone Number	:	807-297-0058
Fax Number	:	817-297-7811

Provider Business Practice Location Address
First Line	:	779 FM 1187 E
Second Line	:
City	:	CROWLEY
State	:	TX
Zip	:	76036-4346
Country	:	US
Telephone Number	:	807-297-0058
Fax Number	:	817-297-7811

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. ODALIS PATRICIA SKUR
Credential	:	DDS
Telephone Number	:	817-297-0058

Provider Enumeration Date	:	02/26/2014
Last Update Date	:	02/26/2014

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Directions to “CROWLEY FAMILY DENTAL CENTER ” Practice Location

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