Provider Demographics
NPI:1760531644
Name:CRANE, MARK ALLEN (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:CRANE
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD43711223S0112X
CAOMS271223S0112X
AZ26402204E00000X
CAA064888204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ545345Medicaid
AZ545345Medicaid