Provider Demographics
NPI:1144065962
Name:CROCKETT, DEVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:DEVIN
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 S LOOMIS ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2195
Mailing Address - Country:US
Mailing Address - Phone:630-390-9002
Mailing Address - Fax:
Practice Address - Street 1:1253 W 18TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3242
Practice Address - Country:US
Practice Address - Phone:773-731-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0352521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice