Healthcare Provider Details

I. General information

NPI: 1740317536
Provider Name (Legal Business Name): MARK DAVID CROSS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 W MARKET ST
GERMANTOWN OH
45327-1715
US

IV. Provider business mailing address

7444 S STIVERS RD
GERMANTOWN OH
45327-8555
US

V. Phone/Fax

Practice location:
  • Phone: 937-855-4704
  • Fax: 937-855-4704
Mailing address:
  • Phone: 937-855-7001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-017598
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: