Provider Demographics
NPI:1437238417
Name:SALAZAR, JUAN CARLOS E (DDS)
Entity Type:Individual
Prefix:
First Name:JUAN CARLOS
Middle Name:E
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-1913
Mailing Address - Country:US
Mailing Address - Phone:203-696-3270
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:982 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1913
Practice Address - Country:US
Practice Address - Phone:203-696-3270
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000100471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0042374788Medicaid
WA5049044Medicaid