Provider Demographics
NPI:1407903040
Name:CRUZ, MARITE RIVERA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARITE
Middle Name:RIVERA
Last Name:CRUZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARITE REGINA
Other - Middle Name:RIVERA
Other - Last Name:CRUZ-TAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:128 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-5717
Mailing Address - Country:US
Mailing Address - Phone:650-871-6303
Mailing Address - Fax:650-871-4103
Practice Address - Street 1:128 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5717
Practice Address - Country:US
Practice Address - Phone:650-871-6303
Practice Address - Fax:650-871-4103
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA385121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice