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General NPI Number Information
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NPI Number | 1124633292
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Entity Type | Individual
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Provider Name | MARIO A CRUZ
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Gender | Male
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Dates
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Enumeration Date | 09/15/2020
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Last Update Date | 09/15/2020
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Provider Practice Location Address
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Address Line | 8829 FIRESTONE PLZ
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City | SOUTH GATE
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State | CA
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Zip | 90280-2612
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Country | US
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Telephone | 323-239-8062
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Fax |
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Provider Business Mailing Address
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Address Line | 8829 FIRESTONE PLZ
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City | SOUTH GATE
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State | CA
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Zip | 90280-2612
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Country | US
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Telephone | 323-239-8062
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 126800000X
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Taxonomy Name | Dental Assistant
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License Number | RDA92366
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License Number State | CA
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