Healthcare Provider Details

I. General information

NPI: 1609935998
Provider Name (Legal Business Name): LISA MARIE MRUZ D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MAIN ST
BUFFALO NY
14209-2308
US

IV. Provider business mailing address

1100 MAIN ST
BUFFALO NY
14209-2308
US

V. Phone/Fax

Practice location:
  • Phone: 716-242-8200
  • Fax:
Mailing address:
  • Phone: 716-242-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number047284-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: