Provider Demographics
NPI:1891081089
Name:CRUZ, KIMBERLY LYNN (RDHAP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:CRUZ
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9877 CHAPMAN AVE STE. D #413
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4565
Mailing Address - Country:US
Mailing Address - Phone:714-638-8709
Mailing Address - Fax:714-638-8917
Practice Address - Street 1:12562 DALE ST UNIT 30
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4565
Practice Address - Country:US
Practice Address - Phone:714-583-8165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP#354124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist