Provider Demographics
NPI:1043736218
Name:ROMAN LEBRON, MODOMI J
Entity Type:Individual
Prefix:
First Name:MODOMI
Middle Name:J
Last Name:ROMAN LEBRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 GUILLERMO RIEFKOHL STREET
Mailing Address - Street 2:
Mailing Address - City:PATILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00723
Mailing Address - Country:US
Mailing Address - Phone:787-839-4320
Mailing Address - Fax:787-271-0004
Practice Address - Street 1:99 GUILLERMO RIEFKKOHL ST
Practice Address - Street 2:
Practice Address - City:PATILLAS
Practice Address - State:PR
Practice Address - Zip Code:00723-0072
Practice Address - Country:US
Practice Address - Phone:787-839-4320
Practice Address - Fax:787-839-4320
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR007527126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR196237OtherREGISTRY CERTIFICATE