Provider Demographics
NPI:1679270748
Name:CRANDALL, JODI L (DHAT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:DHAT
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:L
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DHAT
Mailing Address - Street 1:1001 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8083
Mailing Address - Country:US
Mailing Address - Phone:190-729-7690
Mailing Address - Fax:
Practice Address - Street 1:1001 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8083
Practice Address - Country:US
Practice Address - Phone:190-729-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK23-173-DHAT125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist