Provider Demographics
NPI:1962802710
Name:JORDAN P. CROCKER, D.M.D., PLLC
Entity type:Organization
Organization Name:JORDAN P. CROCKER, D.M.D., PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-638-3661
Mailing Address - Street 1:109 MONUMENT PLACE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180
Mailing Address - Country:US
Mailing Address - Phone:601-638-3661
Mailing Address - Fax:601-631-0401
Practice Address - Street 1:109 MONUMENT PLACE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180
Practice Address - Country:US
Practice Address - Phone:601-638-3661
Practice Address - Fax:601-631-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3672-12261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental