Basic Information
| Provider Information | |||||||||
| NPI: | 1700267911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA CRUZ | ||||||||
| FirstName: | JAVIER | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 919771 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328919771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392783600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11921 SARADRIENNE LN | ||||||||
| Address2: | |||||||||
| City: | BONITA SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341355911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393442322 | ||||||||
| FaxNumber: | 2394957081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2015 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN21345 | FL | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 015143100 | 05 | FL | MEDICAID |