Provider Demographics
NPI:1447773841
Name:CRUZ, ALFONZO (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALFONZO
Middle Name:
Last Name:CRUZ
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 1:6751 CALISTOGA CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-4033
Mailing Address - Country:US
Mailing Address - Phone:386-631-6471
Mailing Address - Fax:
Practice Address - Street 1:1229 PROVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-7362
Practice Address - Country:US
Practice Address - Phone:386-574-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN229211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice