Provider Demographics
NPI:1215006648
Name:DISLA PENA, JOSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:DISLA PENA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 CALLE DELBREY
Mailing Address - Street 2:
Mailing Address - City:SANTURCE
Mailing Address - State:PR
Mailing Address - Zip Code:00911
Mailing Address - Country:US
Mailing Address - Phone:787-725-1703
Mailing Address - Fax:787-724-4622
Practice Address - Street 1:185 CALLE DELBREY
Practice Address - Street 2:
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00911
Practice Address - Country:US
Practice Address - Phone:787-725-1703
Practice Address - Fax:787-724-4622
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3856OtherINTERNATIONAL MEDICAL CAR
PR041560OtherCRUZ AZUL