Provider Demographics
NPI:1811196504
Name:ULLOA, JUAN J (DDS)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:J
Last Name:ULLOA
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 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-857-5650
Mailing Address - Fax:701-857-5031
Practice Address - Street 1:2815 16TH ST SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6914
Practice Address - Country:US
Practice Address - Phone:701-857-2900
Practice Address - Fax:701-857-2910
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41434Medicaid
ND41434Medicaid