Provider Demographics
NPI:1285366534
Name:CRAIG, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:CRAIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12726 TURKEY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61284-9613
Mailing Address - Country:US
Mailing Address - Phone:309-507-1836
Mailing Address - Fax:
Practice Address - Street 1:515 VALLEY VIEW DR STE 105
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6175
Practice Address - Country:US
Practice Address - Phone:309-764-4944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190338211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice