1720297344 NPI number — ST.ELMO W. CRAWFORD D.D.S.P.C.

Table of content: (NPI 1720297344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720297344 NPI number — ST.ELMO W. CRAWFORD D.D.S.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST.ELMO W. CRAWFORD D.D.S.P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CONNECTICUT AVENUE DENTAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720297344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1922 BENNING RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20002-4724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-399-2244
Provider Business Mailing Address Fax Number:
202-399-7800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1922 BENNING RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20002-4724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-399-2244
Provider Business Practice Location Address Fax Number:
202-388-1115
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CRAWFORD
Authorized Official First Name:
ST.ELMO
Authorized Official Middle Name:
WALLACE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
202-399-2244

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DEN3272 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: DEN3272 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: DEN3272 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 035217400 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016851500 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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