Provider Demographics
NPI:1003804857
Name:JUAN, RENE DAVID (DDM)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:DAVID
Last Name:JUAN
Suffix:
Gender:M
Credentials:DDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 CALLE PEDRO SANTOS
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-4015
Mailing Address - Country:US
Mailing Address - Phone:787-877-5865
Mailing Address - Fax:787-877-5865
Practice Address - Street 1:65 CALLE PEDRO SANTOS
Practice Address - Street 2:SUITE 3
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-4015
Practice Address - Country:US
Practice Address - Phone:787-877-5865
Practice Address - Fax:787-877-5865
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001133122300000X
FL0011826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist