Provider Demographics
NPI:1881610855
Name:PACKER, JUAN KEVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:KEVIN
Last Name:PACKER
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 1:2188 SW 176TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5258
Mailing Address - Country:US
Mailing Address - Phone:954-612-4509
Mailing Address - Fax:
Practice Address - Street 1:1321 NW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2139
Practice Address - Country:US
Practice Address - Phone:772-343-0179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3046-981223D0001X
FLDN181881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health