Provider Demographics
NPI:1558761296
Name:CUSCATLAN DENTAL CENTER
Entity Type:Organization
Organization Name:CUSCATLAN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAY
Authorized Official - Middle Name:EVELYN
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-802-3201
Mailing Address - Street 1:1357 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-5815
Mailing Address - Country:US
Mailing Address - Phone:909-635-3738
Mailing Address - Fax:909-635-3736
Practice Address - Street 1:1357 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-5815
Practice Address - Country:US
Practice Address - Phone:909-635-3738
Practice Address - Fax:909-635-3736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-31
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43134122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty