Crockett Pediatric Dentistry, P.a.

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

SC3486 Issued in SC

Legal business name

CROCKETT PEDIATRIC DENTISTRY, P.A.

Practice address

102 S Venture Dr
Greenville, SC 29615-3571

Phone

(864) 234-9800

Fax

(864) 234-9820

NPI assigned

Apr 19, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Jerry W. Crockett

Title

Business Manager

Phone

(864) 234-9800

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Mary Whitaker Crockett, D.M.D.

  • Pediatric Dentistry
  • Greenville, SC
  • NPI 1194805143
  NPD (past)
• Nicole Bate Pruitt, DMD

  • Pediatric Dentistry
  • Greenville, SC
  • NPI 1104897206
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1124245626",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "102 S VENTURE DR",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296153571",
            "telephone_number": "864-234-9800",
            "fax_number": "864-234-9820"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102 S VENTURE DR",
            "city": "GREENVILLE",
            "state": "SC",
            "postal_code": "296153571",
            "telephone_number": "864-234-9800",
            "fax_number": "864-234-9820"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CROCKETT PEDIATRIC DENTISTRY, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-19",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "CROCKETT",
        "authorized_official_first_name": "JERRY",
        "authorized_official_middle_name": "W.",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "864-234-9800",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "SC",
            "license": "SC3486",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZA9507",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Diamond Crider, LPA
• Amy Caitlyn Crisp, APRN
• Halie Carter Crites, PA-C
• Suzanne Nuckolls Crittenden, COTA/L
• Karsyn Blanton Crocker M.S., CCC-SLP
• Amy Hairston Crockett, M.D.
• Jay Anton Crockett, M.D.
• Mary Whitaker Crockett, D.M.D.
• Michele Marie Crockett, RN
• Tabatha Crockett

• Pediatric Dentistry in Greenville, SC
• Providers in Greenville, SC by specialty
• Pediatric Dentistry in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.