Provider Demographics
NPI:1639733116
Name:CROSS CREEK DENTAL
Entity Type:Organization
Organization Name:CROSS CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOD
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-655-4342
Mailing Address - Street 1:10104 SADDLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-7290
Mailing Address - Country:US
Mailing Address - Phone:254-655-4323
Mailing Address - Fax:
Practice Address - Street 1:1199 OLD LORENA RD
Practice Address - Street 2:
Practice Address - City:LORENA
Practice Address - State:TX
Practice Address - Zip Code:76655-3176
Practice Address - Country:US
Practice Address - Phone:254-655-4323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty