Provider Demographics
NPI:1841344173
Name:CROSS, ROBERT EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:CROSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 HICKORY POINT RD
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:IL
Mailing Address - Zip Code:61548-7805
Mailing Address - Country:US
Mailing Address - Phone:309-367-2935
Mailing Address - Fax:
Practice Address - Street 1:134 MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2550
Practice Address - Country:US
Practice Address - Phone:309-699-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A111471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19A11147Medicaid