Provider Demographics
NPI:1649485657
Name:SOC DRES ATILANO LEON, JOSE A MORALES, EDGAR ECHEVARRIA
Entity type:Organization
Organization Name:SOC DRES ATILANO LEON, JOSE A MORALES, EDGAR ECHEVARRIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:GISELA
Authorized Official - Last Name:MONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-374-1181
Mailing Address - Street 1:PO BOX 29736
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00929-0736
Mailing Address - Country:US
Mailing Address - Phone:787-755-4347
Mailing Address - Fax:787-283-7440
Practice Address - Street 1:570 CALLE NAPOLES STE 208
Practice Address - Street 2:CONCORDIA GARDENS SHOPPING CTR
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00924-4605
Practice Address - Country:US
Practice Address - Phone:787-755-4347
Practice Address - Fax:787-283-7440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR004-0826CIOtherSSS PROVIDER NOMBER
PR067099OtherLA CRUZ AZUL PROVIDER NOM
PR4390OtherPMC PROVIDER NOMBER
PR=========OtherOTHER PROVIDERS NOMBER
PR=========OtherOTHER PROVIDERS NOMBER