Provider Demographics
NPI:1437617339
Name:RUIZ LOURIDO, JORGE EDUARDO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:EDUARDO
Last Name:RUIZ LOURIDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W 39TH ST APT 22B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-1792
Mailing Address - Country:US
Mailing Address - Phone:917-873-5050
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:888-700-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-10
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0616451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program