Provider Demographics
NPI:1063597375
Name:CRESTETTO, JOHN MAX (DDS,MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MAX
Last Name:CRESTETTO
Suffix:
Gender:M
Credentials:DDS,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N WINSTEAD AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-8467
Mailing Address - Country:US
Mailing Address - Phone:252-443-7331
Mailing Address - Fax:252-937-2381
Practice Address - Street 1:901 N WINSTEAD AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8467
Practice Address - Country:US
Practice Address - Phone:252-443-7331
Practice Address - Fax:252-937-2381
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0102XMedicaid
NC8990023Medicaid
NC2470371Medicare ID - Type Unspecified
NC8990023Medicaid