Provider Demographics
NPI:1174120463
Name:CRUZ, OWEN RUSSELL (DDS)
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:RUSSELL
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 1:11672 LARGO CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3973
Mailing Address - Country:US
Mailing Address - Phone:949-836-9552
Mailing Address - Fax:
Practice Address - Street 1:29121 NEWPORT RD STE 101
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-5121
Practice Address - Country:US
Practice Address - Phone:951-228-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS105444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist