Healthcare Provider Details

I. General information

NPI: 1710275284
Provider Name (Legal Business Name): JUAN CARLOS CABRERA DMD,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S 16TH ST STE 901
PHILADELPHIA PA
19102-3309
US

IV. Provider business mailing address

220 S 16TH ST STE 901
PHILADELPHIA PA
19102-3309
US

V. Phone/Fax

Practice location:
  • Phone: 215-545-2600
  • Fax:
Mailing address:
  • Phone: 215-545-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS039823
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: