Provider Demographics
NPI:1316954019
Name:CROCKETT, JAMES EVERETT JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EVERETT
Last Name:CROCKETT
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1787 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1154
Mailing Address - Country:US
Mailing Address - Phone:928-445-8980
Mailing Address - Fax:928-445-4117
Practice Address - Street 1:1787 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1154
Practice Address - Country:US
Practice Address - Phone:928-445-8980
Practice Address - Fax:928-445-4117
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA255011223G0001X
AZ21821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice