Provider Demographics
NPI:1144898529
Name:CRUTCHER, JARED (DMD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:CRUTCHER
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 1:1031 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4211
Mailing Address - Country:US
Mailing Address - Phone:618-402-8890
Mailing Address - Fax:
Practice Address - Street 1:3740 E LAKE CTR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5805
Practice Address - Country:US
Practice Address - Phone:217-214-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0331291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty