Provider Demographics
NPI:1831232073
Name:ALONSO, JUAN C (DMD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:C
Last Name:ALONSO
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 1:8321 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4245
Mailing Address - Country:US
Mailing Address - Phone:201-854-7900
Mailing Address - Fax:201-854-7885
Practice Address - Street 1:8321 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4245
Practice Address - Country:US
Practice Address - Phone:201-854-7900
Practice Address - Fax:201-854-7885
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI147571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U46646Medicare UPIN
AL507444Medicare ID - Type Unspecified