MEDICARE: SALVADOR CRUZ D.A

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	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1801112164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALVADOR CRUZ D.A

Provider Business Mailing Address
First Line	:	3807 RANDOLPH ST
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4609
Country	:	US
Telephone Number	:	323-535-9191
Fax Number	:

Provider Business Practice Location Address
First Line	:	9910 LONG BEACH BLVD
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-1561
Country	:	US
Telephone Number	:	323-563-8900
Fax Number	:

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

Provider Enumeration Date	:	04/12/2010
Last Update Date	:	04/12/2010

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