Provider Demographics
NPI:1962547471
Name:CRADDOCK, PATRICIA SUE (DDS)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:SUE
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 BRIGHTON CREEK CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1715
Mailing Address - Country:US
Mailing Address - Phone:702-363-9738
Mailing Address - Fax:
Practice Address - Street 1:820 S 7TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-6938
Practice Address - Country:US
Practice Address - Phone:702-678-1835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2202600Medicaid