MEDICARE: JUAN PABLO PORRAS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN28268	FL

General Provider Information

NPI Number	:	1396421988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN PABLO PORRAS DMD

Provider Business Mailing Address
First Line	:	620 ROYAL PALM WAY
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33325-3016
Country	:	US
Telephone Number	:	954-644-9884
Fax Number	:

Provider Business Practice Location Address
First Line	:	3909 N ANDREWS AVE
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33309-5239
Country	:	US
Telephone Number	:	954-561-6675
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2023
Last Update Date	:	06/27/2023

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