Provider Demographics
NPI:1952831711
Name:VAZQUEZ GRILLO, LISSANDRA MARIA
Entity Type:Individual
Prefix:
First Name:LISSANDRA
Middle Name:MARIA
Last Name:VAZQUEZ GRILLO
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 1:500 CALLE VALCALCER
Mailing Address - Street 2:COOPERATIVA DE VIVIENDAS EL ALCAZAR APARTAMENTO 17 J
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSIDAD DE PUERTO RICO
Practice Address - Street 2:RECINTO DE SCIENCIAS MEDICAS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00935-0001
Practice Address - Country:US
Practice Address - Phone:787-758-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000000001223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health