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Organization
CROCKETT PEDIATRIC DENTISTRY, P.A.
Active
Organization
CROCKETT PEDIATRIC DENTISTRY, P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JERRY W. CROCKETT (BUSINESS MANAGER)
(864) 234-9800
Entity
Organization
Contact information
Practice address
102 S VENTURE DR, GREENVILLE, SC 29615-3571
(864) 234-9800
(864) 234-9820
Mailing address
102 S VENTURE DR, GREENVILLE, SC 29615-3571
(864) 234-9800
(864) 234-9820
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
SC3486
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
ZA9507
—
SC
Enumeration date
04/19/2007
Last updated
08/22/2020
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