Healthcare Provider Details

I. General information

NPI: 1801112164
Provider Name (Legal Business Name): SALVADOR CRUZ D.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9910 LONG BEACH BLVD
LYNWOOD CA
90262-1561
US

IV. Provider business mailing address

3807 RANDOLPH ST
HUNTINGTON PARK CA
90255-4609
US

V. Phone/Fax

Practice location:
  • Phone: 323-563-8900
  • Fax:
Mailing address:
  • Phone: 323-535-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: