Healthcare Provider Details

I. General information

NPI: 1801941422
Provider Name (Legal Business Name): MANUEL LUIS IRAVEDRA D.M.D., B.S.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MANUEL LUIS IRAVEDRA GONZALEZ DMD, B.S.PH.

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX PH
CHINLE AZ
86503-8000
US

IV. Provider business mailing address

1814 CALLE GLASGOW COLLEGE PARK
SAN JUAN PR
00921-4814
US

V. Phone/Fax

Practice location:
  • Phone: 928-674-7001
  • Fax:
Mailing address:
  • Phone: 787-758-8510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD1388
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2750
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: