Provider Demographics
NPI:1699989475
Name:SLACK, CRAIG ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALLEN
Last Name:SLACK
Suffix:
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 1:3600 OLENTANGY RIVER RD
Mailing Address - Street 2:BLDG. 485
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3437
Mailing Address - Country:US
Mailing Address - Phone:614-268-5744
Mailing Address - Fax:614-268-4109
Practice Address - Street 1:3600 OLENTANGY RIVER RD
Practice Address - Street 2:BLDG. 485
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3437
Practice Address - Country:US
Practice Address - Phone:614-268-5744
Practice Address - Fax:614-268-4109
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30018548122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist