Provider Demographics
NPI:1558315838
Name:CROSSLAND, JAY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:ALAN
Last Name:CROSSLAND
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 1:3415 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7365
Mailing Address - Country:US
Mailing Address - Phone:605-348-6818
Mailing Address - Fax:605-348-4690
Practice Address - Street 1:3415 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7365
Practice Address - Country:US
Practice Address - Phone:605-348-6818
Practice Address - Fax:605-348-4690
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD06211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8000500Medicaid
SDV10569Medicare UPIN
SDS101283Medicare PIN