Provider Demographics
NPI:1508975129
Name:CRUZADO, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:CRUZADO
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:PO BOX 6984
Mailing Address - Street 2:SANTA ROSA UNIT
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-5984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AVE MINILLAS DC 8
Practice Address - Street 2:URB. SANTA JUANITA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-643-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist