MEDICARE: IVAN LEANDROS CUEVAS RUIZ

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	DN24403	FL

General Provider Information

NPI Number	:	1588217178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN LEANDROS CUEVAS RUIZ

Provider Business Mailing Address
First Line	:	3304 GREENWALD WAY N
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-0768
Country	:	US
Telephone Number	:	786-715-7999
Fax Number	:

Provider Business Practice Location Address
First Line	:	3304 GREENWALD WAY N
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-0768
Country	:	US
Telephone Number	:	407-520-3595
Fax Number	:

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

Provider Enumeration Date	:	07/22/2019
Last Update Date	:	01/17/2025

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