Provider Demographics
NPI:1942475835
Name:CHAUNCEY CROSS DDS LTD
Entity Type:Organization
Organization Name:CHAUNCEY CROSS DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CHAUNCEY
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-787-0212
Mailing Address - Street 1:1001 CLOCK TOWER DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1383
Mailing Address - Country:US
Mailing Address - Phone:217-787-0212
Mailing Address - Fax:217-793-1490
Practice Address - Street 1:1001 CLOCK TOWER DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1383
Practice Address - Country:US
Practice Address - Phone:217-787-0212
Practice Address - Fax:217-793-1490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190201911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty