Provider Demographics
NPI:1982717328
Name:CROSS, KENNETH DETLAF (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DETLAF
Last Name:CROSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:510 MAIN ST
Mailing Address - City:BENTON
Mailing Address - State:PA
Mailing Address - Zip Code:17814
Mailing Address - Country:US
Mailing Address - Phone:570-925-5011
Mailing Address - Fax:570-925-2943
Practice Address - Street 1:510 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:PA
Practice Address - Zip Code:17814
Practice Address - Country:US
Practice Address - Phone:570-925-5011
Practice Address - Fax:570-925-2943
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026724L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist