Provider Demographics
NPI:1659379303
Name:DOMINGUEZ CARRAZQUILLO, LUIS ALBERTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALBERTO
Last Name:DOMINGUEZ CARRAZQUILLO
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:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-0623
Mailing Address - Country:US
Mailing Address - Phone:787-866-3631
Mailing Address - Fax:787-866-8690
Practice Address - Street 1:CALLE PALMER SUR #24
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784-7610
Practice Address - Country:US
Practice Address - Phone:787-866-3631
Practice Address - Fax:787-866-8690
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR40624OtherCRUZ AZUL
PR1099OtherMENONITA
PR26016OtherAMERICAN HEALTH
PR4-1072OtherTRIPLE SSS
PR1099OtherUIA
PR6540025OtherHUMANA
PR8634OtherIMC