Provider Demographics
NPI:1689758534
Name:IRAVEDRA, DIEGO G (DMD)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:G
Last Name:IRAVEDRA
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 1:212 LA HIJA DEL CARIBE LOS MAESTROS
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-765-8176
Mailing Address - Fax:787-765-8176
Practice Address - Street 1:124 WINSTON CHURCHILL
Practice Address - Street 2:SUITE 3 CROWN HILL
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-765-8176
Practice Address - Fax:787-765-8196
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist