Provider Demographics
NPI:1386638088
Name:FADHEL, GUSTAVO (DMD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:FADHEL
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:LUIS MUNOZ MARIN AVE. STE 206
Mailing Address - Street 2:QUADRANGLE MEDICAL CENTER
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-746-0895
Mailing Address - Fax:
Practice Address - Street 1:SAN JUAN CITY HOSPITAL
Practice Address - Street 2:MEDICAL CENTER
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936
Practice Address - Country:US
Practice Address - Phone:787-766-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16851223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1223P0700XOtherTAXONOMY
PR4-1932Medicare ID - Type Unspecified