Provider Demographics
NPI:1619026564
Name:WOODLANDS ORAL & MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:WOODLANDS ORAL & MAXILLOFACIAL SURGERY PC
Other - Org Name:MARK A. CRANE DDS MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD,DDS
Authorized Official - Phone:928-214-7052
Mailing Address - Street 1:1635 S PLAZA WAY
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7102
Mailing Address - Country:US
Mailing Address - Phone:928-214-7052
Mailing Address - Fax:928-214-7059
Practice Address - Street 1:1635 S PLAZA WAY
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7102
Practice Address - Country:US
Practice Address - Phone:928-214-7052
Practice Address - Fax:928-214-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26402204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ545345Medicaid
CA692328Medicare UPIN