Provider Demographics
NPI:1194805143
Name:CROCKETT, MARY WHITAKER (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:WHITAKER
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S VENTURE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3571
Mailing Address - Country:US
Mailing Address - Phone:864-234-9800
Mailing Address - Fax:864-234-9820
Practice Address - Street 1:102 S VENTURE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3571
Practice Address - Country:US
Practice Address - Phone:864-234-9800
Practice Address - Fax:864-234-9820
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC34861223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9507Medicaid
SCZA9507Medicaid