Healthcare Provider Details

I. General information

NPI: 1225697402
Provider Name (Legal Business Name): KRISTINE VINCENT CRUZ ANGELES DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CALLE PORAL
SIERRA VISTA AZ
85635
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-3011
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-6852
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD010393
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: