Provider Demographics
NPI:1053143073
Name:LILY B AND SAMUEL D CROCCO DMD PLLC
Entity type:Organization
Organization Name:LILY B AND SAMUEL D CROCCO DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:760-750-0087
Mailing Address - Street 1:25642 BERRYHILL RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9603
Mailing Address - Country:US
Mailing Address - Phone:760-750-0087
Mailing Address - Fax:
Practice Address - Street 1:358 FRONT AVE NW
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611-8996
Practice Address - Country:US
Practice Address - Phone:760-750-0087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental