Healthcare Provider Details

I. General information

NPI: 1588637359
Provider Name (Legal Business Name): JUAN ISRAEL MEDINA JR. D.D.S. M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PONCE DE LEON #735 TORRE MEDICO DENTAL AUXILIO MUTUO SUITE #607
SAN JUAN PR
00917-5028
US

IV. Provider business mailing address

TORRE MEDICO DENTAL AUXILIO MUTUO SUITE #607 PONCE DE LEON #735
SAN JUAN PR
00917-5028
US

V. Phone/Fax

Practice location:
  • Phone: 787-767-7850
  • Fax:
Mailing address:
  • Phone: 787-767-7850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2076
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: