Healthcare Provider Details

I. General information

NPI: 1366416349
Provider Name (Legal Business Name): WANDA CRUZ-GONZALEZ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S FIRST AVE 101 1740 LOYOLA UNIVERSITY MEDICAL CENTER
MAYWOOD IL
60153
US

IV. Provider business mailing address

2160 S FIRST AVE 101 1740 LOYOLA UNIVERSITY MEDICAL CENTER
MAYWOOD IL
60153
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax: 708-216-9033
Mailing address:
  • Phone: 708-216-9000
  • Fax: 708-216-9033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number36055205
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: