Basic Information
| Provider Information | |||||||||
| NPI: | 1366416349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUZ-GONZALEZ | ||||||||
| FirstName: | WANDA | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 S FIRST AVE | ||||||||
| Address2: | 101 1740 LOYOLA UNIVERSITY MEDICAL CENTER | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
| FaxNumber: | 7082169033 | ||||||||
| Practice Location | |||||||||
| Address1: | 2160 S FIRST AVE | ||||||||
| Address2: | 101 1740 LOYOLA UNIVERSITY MEDICAL CENTER | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
| FaxNumber: | 7082169033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 36055205 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 1223S0112X | IL | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 36055205 | 05 | IL | MEDICAID |