Provider Demographics
NPI:1902255375
Name:PEREZ, MIGUEL ANGEL JR
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:PEREZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4431 68TH ST
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5042
Mailing Address - Country:US
Mailing Address - Phone:254-286-7401
Mailing Address - Fax:
Practice Address - Street 1:4431 68TH ST
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5042
Practice Address - Country:US
Practice Address - Phone:254-286-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY351819323124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist