=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902057979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLA DE LA CRUZ DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2008
-----------------------------------------------------
Last Update Date | 02/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1509 DODONA TER SUITE 105A
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20175-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-293-0244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1509 DODONA TER STE 105A
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20175-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-293-0244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0401412920
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------