Provider Demographics
NPI:1073807426
Name:CROSS, RANDOLPH ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:ROBERT
Last Name:CROSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 S GREEN VALLEY RD STE 7
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3077
Mailing Address - Country:US
Mailing Address - Phone:831-536-5295
Mailing Address - Fax:831-536-5296
Practice Address - Street 1:390 S GREEN VALLEY RD STE 7
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3077
Practice Address - Country:US
Practice Address - Phone:831-536-5295
Practice Address - Fax:831-536-5296
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA628901223E0200X
NMDD3517122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist