Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DD3517 | NM |
Y | 1223E0200X | Endodontist | 62890 | CA |
NPI | 1073807426 |
---|---|
Provider Name | Randolph Robert Cross |
First Address | Watsonville, CA 95076-2059 |
Second Address | Watsonville, CA 95076-4869 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2011 |
Last Update Date | 28/07/2021 |