Provider Demographics
NPI:1548341514
Name:SANTIAGO, IVAN JOSE (DMD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:JOSE
Last Name: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 1:89 AVE DE DIEGO PMB 643
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-6372
Mailing Address - Country:US
Mailing Address - Phone:787-647-7330
Mailing Address - Fax:
Practice Address - Street 1:85 JOSE CELSO BARBOSA
Practice Address - Street 2:
Practice Address - City:LAS PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00771
Practice Address - Country:US
Practice Address - Phone:787-647-7330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR25071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice