Provider Demographics
NPI:1053814277
Name:PEREZ VILLANUEVA, NAIOMY
Entity Type:Individual
Prefix:
First Name:NAIOMY
Middle Name:
Last Name:PEREZ VILLANUEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20351 BEACONSFIELD ST APT 4
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1369
Mailing Address - Country:US
Mailing Address - Phone:787-203-2097
Mailing Address - Fax:
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3305122300000X
390200000X
MI2952000752390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist