Provider Demographics
NPI:1275888133
Name:DE LA CRUZ, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ARTERIAL HOSTOS
Mailing Address - Street 2:COND HATO REY CENTRO EDF O APT 301
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-342-9334
Mailing Address - Fax:
Practice Address - Street 1:130 AVE ARTERIAL HOSTOS
Practice Address - Street 2:COND HATO REY CENTRO EDF O APT 301
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-5200
Practice Address - Country:US
Practice Address - Phone:787-342-9334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5257126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant