Basic Information
Provider Information
NPI: 1003804857
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JUAN
FirstName: RENE
MiddleName: DAVID
NamePrefix: DR.
NameSuffix:  
Credential: D.D.M.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 65 CALLE PEDRO SANTOS
Address2: SUITE 3
City: MOCA
State: PR
PostalCode: 006764015
CountryCode: US
TelephoneNumber: 7878775865
FaxNumber: 7878775865
Practice Location
Address1: 65 CALLE PEDRO SANTOS
Address2: SUITE 3
City: MOCA
State: PR
PostalCode: 006764015
CountryCode: US
TelephoneNumber: 7878775865
FaxNumber: 7878775865
Other Information
ProviderEnumerationDate: 10/06/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X0011826FLN Dental ProvidersDentist 
122300000X001133PRY Dental ProvidersDentist 

No ID Information.


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