Provider Demographics
NPI:1356317549
Name:ANDUJAR-MATOS, ILSA J (DMD)
Entity Type:Individual
Prefix:DR
First Name:ILSA
Middle Name:J
Last Name:ANDUJAR-MATOS
Suffix:
Gender:F
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:PMB 292
Mailing Address - Street 2:100 GRAND PASEO BLVD STE 112
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5955
Mailing Address - Country:US
Mailing Address - Phone:787-400-7919
Mailing Address - Fax:
Practice Address - Street 1:123 AVE BARBOSA
Practice Address - Street 2:
Practice Address - City:CATANO
Practice Address - State:PR
Practice Address - Zip Code:00962-6070
Practice Address - Country:US
Practice Address - Phone:787-275-0605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice