Provider Demographics
NPI:1639206253
Name:IZCOA, CARLOS ANTONIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ANTONIO
Last Name:IZCOA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:D9 CALLE 1
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-6908
Mailing Address - Country:US
Mailing Address - Phone:787-798-1772
Mailing Address - Fax:
Practice Address - Street 1:B9 CALLE SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6902
Practice Address - Country:US
Practice Address - Phone:787-798-1772
Practice Address - Fax:787-288-5021
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22441223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics