Healthcare Provider Details

I. General information

NPI: 1770100125
Provider Name (Legal Business Name): ELIZABETH CRUZ-CRUZ EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST STE 210
GRESHAM OR
97030-7341
US

IV. Provider business mailing address

4850 SW 11TH ST APT 115
GRESHAM OR
97080-7312
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-4900
  • Fax:
Mailing address:
  • Phone: 503-957-0562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: