Provider Demographics
NPI:1679702435
Name:CRAWFORD, JERROD R (DDS)
Entity type:Individual
Prefix:DR
First Name:JERROD
Middle Name:R
Last Name:CRAWFORD
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 1:5804 NEW COPELAND RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-6217
Mailing Address - Country:US
Mailing Address - Phone:903-747-3929
Mailing Address - Fax:903-561-1814
Practice Address - Street 1:5804 NEW COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6217
Practice Address - Country:US
Practice Address - Phone:903-747-3929
Practice Address - Fax:903-561-1814
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice