Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 3799-15 | MS |
N | 1223P0221X | Pediatric Dentist | 0442000266 | VA |
N | 1223P0221X | Pediatric Dentist | 6838 | LA |
Y | 1223P0221X | Pediatric Dentist | D.0006743-C1 | AL |
NPI | 1104208651 |
---|---|
Provider Name | Dr. Carson Myles Cruise |
First Address | Florence, AL 35630-1759 |
Second Address | Florence, AL 35630-1759 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2015 |
Last Update Date | 28/07/2020 |