Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0007X | Plastic Surgeon (Head & Neck) | G42104 | CA |
NPI | 1356362800 |
---|---|
Provider Name | Dennis M Crockett |
First Address | Mission Viejo, CA 92691 |
Second Address | Mission Viejo, CA 92691 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 26/11/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G421040 | (05) | CA |
A02735 | (02) | |
W8109 | GEL PTAN (01) |