Healthcare Provider Details

I. General information

NPI: 1215406053
Provider Name (Legal Business Name): CROSSROADS DSM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2018
Last Update Date: 11/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 GUION RD STE 280
INDIANAPOLIS IN
46222-1696
US

IV. Provider business mailing address

3750 GUION RD STE 280
INDIANAPOLIS IN
46222-1696
US

V. Phone/Fax

Practice location:
  • Phone: 765-335-6694
  • Fax:
Mailing address:
  • Phone: 765-336-6694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. CLAYTON THOMAS CRAIG
Title or Position: CEO
Credential: DDS, MS
Phone: 765-335-6694