Provider Demographics
NPI:1174511844
Name:WISCOVITCH, JOSE GUSTAVO (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:GUSTAVO
Last Name:WISCOVITCH
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 8053 MARINA STATION
Mailing Address - Street 2:
Mailing Address - City:MAYAQUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681
Mailing Address - Country:US
Mailing Address - Phone:787-891-9155
Mailing Address - Fax:787-882-8050
Practice Address - Street 1:AVE. PEDRO ALBIZU CAMPOS # 2022
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-891-9155
Practice Address - Fax:787-882-8050
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13851223E0200X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology