MEDICARE: DR. ULISES C DE LA CRUZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	17630	TX

General Provider Information

NPI Number	:	1285611087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ULISES C DE LA CRUZ DDS

Provider Business Mailing Address
First Line	:	1 LONE STAR PASS BLDG 46
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78264-3650
Country	:	US
Telephone Number	:	210-263-5749
Fax Number	:	210-263-5752

Provider Business Practice Location Address
First Line	:	1 LONE STAR PASS BLDG 46
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78264-3650
Country	:	US
Telephone Number	:	210-263-5749
Fax Number	:	210-263-5752

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	03/14/2018

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