Provider Demographics
NPI:1760595334
Name:IRAVEDRA, LUIS C (DMD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:C
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:P.O.BOX 1326
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00954-0000
Mailing Address - Country:US
Mailing Address - Phone:787-870-2019
Mailing Address - Fax:
Practice Address - Street 1:CALLE 1 A2
Practice Address - Street 2:URB.SAN FERNANDO
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-0000
Practice Address - Country:US
Practice Address - Phone:787-870-2019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice