Provider Demographics
NPI:1104154384
Name:TORRES- SANTIAGO, IVAN (DMD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:TORRES- SANTIAGO
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:PO BOX 801207
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-1207
Mailing Address - Country:US
Mailing Address - Phone:787-844-5727
Mailing Address - Fax:787-844-5727
Practice Address - Street 1:1034 AVE HOSTOS
Practice Address - Street 2:CENTRO DE DIAGNOSTICO Y TRATAMIENTO DE LA PLAYA
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-1115
Practice Address - Country:US
Practice Address - Phone:787-844-5727
Practice Address - Fax:787-844-5727
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR28511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice