| Crocker Family Dental | |
|
109 Monument Place Vicksburg MS 39180 | |
| (601) 638-3661 | |
| (601) 631-0401 |
| Full Name | Crocker Family Dental |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 109 Monument Place, Vicksburg, Mississippi |
| Authorized Official Name and Position | Jordan P Crocker (OWNER) |
| Authorized Official Contact | 6016383661 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Crocker Family Dental 109 Monument Place Vicksburg MS 39180 Ph: (601) 638-3661 | Crocker Family Dental 109 Monument Place Vicksburg MS 39180 Ph: (601) 638-3661 |
| NPI Number | 1962802710 |
|---|---|
| Provider Enumeration Date | 08/29/2014 |
| Last Update Date | 01/09/2019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962802710 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | 3672-12 (Mississippi) | Primary |
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