Provider Demographics
NPI:1073043758
Name:CROSSTOWN DENTAL GROUP
Entity Type:Organization
Organization Name:CROSSTOWN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:KIESSLING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-648-8695
Mailing Address - Street 1:7230 REDTOP RD
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-9556
Mailing Address - Country:US
Mailing Address - Phone:717-648-8695
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-9505
Practice Address - Country:US
Practice Address - Phone:717-838-5425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025189L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty