MEDICARE: DR. BRENDA MAYORGA DE LA CRUZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12014411A	IN

General Provider Information

NPI Number	:	1174364822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENDA MAYORGA DE LA CRUZ DDS

Provider Business Mailing Address
First Line	:	426 SPEEDWAY WOODS DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-6142
Country	:	US
Telephone Number	:	317-828-2601
Fax Number	:

Provider Business Practice Location Address
First Line	:	1002 N MITTHOEFER RD STE B
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-2461
Country	:	US
Telephone Number	:	317-898-6666
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2024
Last Update Date	:	06/28/2024

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