Healthcare Provider Details

I. General information

NPI: 1467459586
Provider Name (Legal Business Name): JAVIER A AYALA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

M10 AVE CONQUISTADOR VALLE VERDE PLAZA DEL RIO SUITE 201
FAJARDO PR
00738
US

IV. Provider business mailing address

PO BOX 9150
HUMACAO PR
00792-9150
US

V. Phone/Fax

Practice location:
  • Phone: 787-860-4223
  • Fax: 787-863-6972
Mailing address:
  • Phone: 787-860-4223
  • Fax: 787-863-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2563
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: