Healthcare Provider Details

I. General information

NPI: 1003804857
Provider Name (Legal Business Name): RENE DAVID JUAN D.D.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CALLE PEDRO SANTOS SUITE 3
MOCA PR
00676-4015
US

IV. Provider business mailing address

65 CALLE PEDRO SANTOS SUITE 3
MOCA PR
00676-4015
US

V. Phone/Fax

Practice location:
  • Phone: 787-877-5865
  • Fax: 787-877-5865
Mailing address:
  • Phone: 787-877-5865
  • Fax: 787-877-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number001133
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0011826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: