Provider Demographics
NPI:1194123638
Name:CRANDALL CRUZ, MARISSA (DMD, MS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CRANDALL CRUZ
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3838
Mailing Address - Country:US
Mailing Address - Phone:352-460-0164
Mailing Address - Fax:
Practice Address - Street 1:26540 ACE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8279
Practice Address - Country:US
Practice Address - Phone:352-326-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039658122300000X
FLDN237971223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist