Provider Demographics
NPI:1568737625
Name:SAN JUAN, SR, FERNANDO O (DDS)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:O
Last Name:SAN JUAN, SR
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 1:6882 CORAL WAY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1704
Mailing Address - Country:US
Mailing Address - Phone:305-662-8995
Mailing Address - Fax:305-666-7150
Practice Address - Street 1:6882 CORAL WAY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1704
Practice Address - Country:US
Practice Address - Phone:305-662-8995
Practice Address - Fax:305-666-7150
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11002122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist