Provider Demographics
NPI:1558341594
Name:CROSSLEY, DENNIS DAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:DAN
Last Name:CROSSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 MCKENNA DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2143
Mailing Address - Country:US
Mailing Address - Phone:208-587-9703
Mailing Address - Fax:208-580-9812
Practice Address - Street 1:465 MCKENNA DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2143
Practice Address - Country:US
Practice Address - Phone:208-587-9703
Practice Address - Fax:208-580-9812
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM 8024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144275Medicare ID - Type Unspecified
H12841Medicare UPIN