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General NPI Number Information
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NPI Number | 1639733116
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Entity Type | Organization
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Legal Business Name | CROSS CREEK DENTAL
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Dates
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Enumeration Date | 04/30/2019
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Last Update Date | 04/30/2019
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Provider Practice Location Address
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Address Line | 1199 OLD LORENA RD
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City | LORENA
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State | TX
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Zip | 76655-3176
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Country | US
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Telephone | 254-655-4323
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Fax |
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Provider Business Mailing Address
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Address Line | 10104 SADDLE CREEK RD
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City | WACO
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State | TX
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Zip | 76708-7290
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Country | US
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Telephone | 254-655-4323
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DOD DAVID MOORE
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Credential | DDS
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Telephone | 254-655-4342
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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