Basic Information
| Provider Information | |||||||||
| NPI: | 1811196504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ULLOA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5010 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587025010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575650 | ||||||||
| FaxNumber: | 7018575031 | ||||||||
| Practice Location | |||||||||
| Address1: | 2815 16TH ST SW | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587016914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018572900 | ||||||||
| FaxNumber: | 7018572910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 05/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 176 | FL | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 41434 | 05 | ND | MEDICAID |