Provider Demographics
NPI:1417039140
Name:MCCRACKEN, ROBERT GRANT SR (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GRANT
Last Name:MCCRACKEN
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 STOOPS DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MONONGAHELA
Mailing Address - State:PA
Mailing Address - Zip Code:15063-3553
Mailing Address - Country:US
Mailing Address - Phone:724-483-5000
Mailing Address - Fax:724-483-5001
Practice Address - Street 1:100 STOOPS DR
Practice Address - Street 2:SUITE 260
Practice Address - City:MONONGAHELA
Practice Address - State:PA
Practice Address - Zip Code:15063-3553
Practice Address - Country:US
Practice Address - Phone:724-483-5000
Practice Address - Fax:724-483-5001
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030969L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01752378Medicaid