MEDICARE: MELISSA Y CRUZ

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	39617	TX

General Provider Information

NPI Number	:	1336840404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA Y CRUZ

Provider Business Mailing Address
First Line	:	348 GILBERT CIR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-6581
Country	:	US
Telephone Number	:	972-655-4056
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 N TARRANT PKWY STE 101
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-7307
Country	:	US
Telephone Number	:	817-534-6455
Fax Number	:

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

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	07/18/2023

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Directions to “ MELISSA Y CRUZ ” Practice Location

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