Provider Demographics
NPI:1225528516
Name:DE LA CRUZ, PABLO ALEXANDER (DDS)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:ALEXANDER
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:DE LA CRUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:225 PHOEBE LN
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:NY
Mailing Address - Zip Code:13753-3468
Mailing Address - Country:US
Mailing Address - Phone:607-746-3555
Mailing Address - Fax:
Practice Address - Street 1:225 PHOEBE LN
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:NY
Practice Address - Zip Code:13753
Practice Address - Country:US
Practice Address - Phone:607-746-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2019-09-18
Deactivation Date:2019-09-03
Deactivation Code:
Reactivation Date:2019-09-17
Provider Licenses
StateLicense IDTaxonomies
NY0607221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice