Provider Demographics
NPI:1235683830
Name:CRUM, PHILLIP (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:CRUM
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 1:2581 DEVELOPMENT DR STE 204
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4248
Mailing Address - Country:US
Mailing Address - Phone:920-347-2640
Mailing Address - Fax:
Practice Address - Street 1:2581 DEVELOPMENT DR STE 204
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WI
Practice Address - Zip Code:54311-4248
Practice Address - Country:US
Practice Address - Phone:920-347-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002021-151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics