Provider Demographics
NPI:1487702049
Name:CRAVEN, DUSTIN R
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:R
Last Name:CRAVEN
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 1:315 E BROMLEY LN
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-3065
Mailing Address - Country:US
Mailing Address - Phone:303-659-1125
Mailing Address - Fax:
Practice Address - Street 1:315 E BROMLEY LN
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-3065
Practice Address - Country:US
Practice Address - Phone:303-659-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-88531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1875045OtherCO MEDICAID
CO15502341Medicaid