Healthcare Provider Details

I. General information

NPI: 1902106537
Provider Name (Legal Business Name): CARLOS MIGUEL NIEVES MENDEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 07/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 CALLE CONCEPCION VERA # A-1
MOCA PR
00676-5073
US

IV. Provider business mailing address

HC 59 BOX 6126
AGUADA PR
00602-9659
US

V. Phone/Fax

Practice location:
  • Phone: 787-284-0000
  • Fax:
Mailing address:
  • Phone: 787-363-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2863
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: