MEDICARE: RANDOLPH ROBERT CROSS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	62890	CA
2	122300000X	Dentist	DD3517	NM

General Provider Information

NPI Number	:	1073807426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDOLPH ROBERT CROSS DDS

Provider Business Mailing Address
First Line	:	390 S GREEN VALLEY RD STE 7
Second Line	:
City	:	WATSONVILLE
State	:	CA
Zip	:	95076-3077
Country	:	US
Telephone Number	:	831-536-5295
Fax Number	:	831-536-5296

Provider Business Practice Location Address
First Line	:	390 S GREEN VALLEY RD STE 7
Second Line	:
City	:	WATSONVILLE
State	:	CA
Zip	:	95076-3077
Country	:	US
Telephone Number	:	831-536-5295
Fax Number	:	831-536-5296

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2011
Last Update Date	:	09/27/2023

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