Provider Demographics
NPI:1194179036
Name:CROSS CREEK FAMILY DENTAL
Entity Type:Organization
Organization Name:CROSS CREEK FAMILY DENTAL
Other - Org Name:CROSS CREEK FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:J
Authorized Official - Last Name:SKALSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-273-1544
Mailing Address - Street 1:3915 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3087
Mailing Address - Country:US
Mailing Address - Phone:330-237-1544
Mailing Address - Fax:
Practice Address - Street 1:3915 CENTER RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3087
Practice Address - Country:US
Practice Address - Phone:330-237-1544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.016564122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30.016564OtherOHIO LICENSE 30.016564