Provider Demographics
NPI:1730826249
Name:ALFONSO CRUZ DMD PA
Entity type:Organization
Organization Name:ALFONSO CRUZ DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-631-6471
Mailing Address - Street 1:1657 TAYLOR RD STE 106
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7516
Mailing Address - Country:US
Mailing Address - Phone:386-631-6471
Mailing Address - Fax:
Practice Address - Street 1:1657 TAYLOR RD STE 106
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-7516
Practice Address - Country:US
Practice Address - Phone:386-631-6471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALFONSO CRUZ DMD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental