Provider Demographics
NPI:1588637359
Name:MEDINA, JUAN ISRAEL JR (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:ISRAEL
Last Name:MEDINA
Suffix:JR
Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:TORRE MEDICO DENTAL AUXILIO MUTUO
Mailing Address - Street 2:SUITE #607 PONCE DE LEON #735
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-5028
Mailing Address - Country:US
Mailing Address - Phone:787-767-7850
Mailing Address - Fax:
Practice Address - Street 1:PONCE DE LEON #735 TORRE MEDICO DENTAL AUXILIO MUTUO
Practice Address - Street 2:SUITE #607
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-5028
Practice Address - Country:US
Practice Address - Phone:787-767-7850
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR20761223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR206674OtherUTI
PR42135MEOtherSSS
PR9690066OtherHUMANA
041823OtherCRUZ AZUL