=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528843323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDOLPH CROSS DDS, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2023
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 S GREEN VALLEY RD STE 7
-----------------------------------------------------
City | WATSONVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95076-3077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-536-5295
-----------------------------------------------------
Fax | 831-536-5296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 390 S GREEN VALLEY RD STE 7
-----------------------------------------------------
City | WATSONVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95076-3077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-536-5295
-----------------------------------------------------
Fax | 831-536-5296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RANDOLPH ROBERT CROSS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 831-536-5295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------