1467566018 NPI number — SAMUEL RAY CROSS DDS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467566018 NPI number — SAMUEL RAY CROSS DDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMUEL RAY CROSS DDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467566018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1736
Provider Second Line Business Mailing Address:
401 DOCTORS CIRCLE
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-862-2892
Provider Business Mailing Address Fax Number:
910-862-6345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 DOCTORS CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-862-2892
Provider Business Practice Location Address Fax Number:
910-862-6345
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-862-2892

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4625 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8991904 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91904 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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