Provider Demographics
NPI:1073059861
Name:PARK-CRUZ, JENNIFER (DR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PARK-CRUZ
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 WILSHIRE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1132
Mailing Address - Country:US
Mailing Address - Phone:213-385-0053
Mailing Address - Fax:
Practice Address - Street 1:2975 WILSHIRE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1132
Practice Address - Country:US
Practice Address - Phone:213-385-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA511261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice