Provider Demographics
NPI:1508929894
Name:BRAVO, RICARDO JOSE (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:JOSE
Last Name:BRAVO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:RICARDO
Other - Middle Name:J
Other - Last Name:BRAVO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 403
Mailing Address - Street 2:
Mailing Address - City:JUNCOS
Mailing Address - State:PR
Mailing Address - Zip Code:00777-0403
Mailing Address - Country:US
Mailing Address - Phone:787-734-1575
Mailing Address - Fax:787-734-1575
Practice Address - Street 1:51 CALLE MUNOZ RIVERA
Practice Address - Street 2:LOCAL #3
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777-0000
Practice Address - Country:US
Practice Address - Phone:787-734-1575
Practice Address - Fax:787-734-1575
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR66-0477764OtherEIN
PR$$$$$$$$$OtherSOCIAL SECURITY