Provider Demographics
NPI:1083710511
Name:DE JESUS, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:DE JESUS
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:PO BOX 1694
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745
Mailing Address - Country:US
Mailing Address - Phone:787-888-1228
Mailing Address - Fax:787-888-1228
Practice Address - Street 1:41 CALLE PIMENTEL
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-888-1228
Practice Address - Fax:787-888-1228
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist