Provider Demographics
NPI:1912524315
Name:CRUZ, MAVI (DMD)
Entity Type:Individual
Prefix:
First Name:MAVI
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 NW LEONARDO CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-4350
Mailing Address - Country:US
Mailing Address - Phone:786-546-0663
Mailing Address - Fax:
Practice Address - Street 1:1405 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4700
Practice Address - Country:US
Practice Address - Phone:772-465-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN250921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice