Healthcare Provider Details

I. General information

NPI: 1447773841
Provider Name (Legal Business Name): ALFONZO CRUZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 PROVIDENCE BLVD
DELTONA FL
32725-7362
US

IV. Provider business mailing address

6751 CALISTOGA CIR
PORT ORANGE FL
32128-4033
US

V. Phone/Fax

Practice location:
  • Phone: 386-574-8388
  • Fax:
Mailing address:
  • Phone: 386-631-6471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN22921
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: