Provider Demographics
NPI:1104208651
Name:CRUISE, CARSON MYLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARSON
Middle Name:MYLES
Last Name:CRUISE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 ANA DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1759
Mailing Address - Country:US
Mailing Address - Phone:256-766-0270
Mailing Address - Fax:256-766-8328
Practice Address - Street 1:162 ANA DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1759
Practice Address - Country:US
Practice Address - Phone:256-766-0270
Practice Address - Fax:256-766-8328
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3799-15122300000X
LA68381223P0221X
VA04420002661223P0221X
ALD.0006743-C11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist