Provider Demographics
NPI:1720063589
Name:CRUZ, JON E (DDS)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:CRUZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 JOHNSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-2108
Mailing Address - Country:US
Mailing Address - Phone:320-629-2282
Mailing Address - Fax:320-629-3357
Practice Address - Street 1:505 JOHNSON AVE SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-2108
Practice Address - Country:US
Practice Address - Phone:320-629-2282
Practice Address - Fax:320-629-3357
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice