Provider Demographics
NPI:1942212907
Name:REYES, LISELIE
Entity Type:Individual
Prefix:
First Name:LISELIE
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:
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 625
Mailing Address - Street 2:
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-0625
Mailing Address - Country:US
Mailing Address - Phone:787-846-0352
Mailing Address - Fax:787-846-0352
Practice Address - Street 1:CARR. #2 KM. 55.5 BO. PALENQUE
Practice Address - Street 2:
Practice Address - City:BARCELONETA
Practice Address - State:PR
Practice Address - Zip Code:00617
Practice Address - Country:US
Practice Address - Phone:787-846-0352
Practice Address - Fax:787-846-0352
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1812122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist