Provider Demographics
NPI:1548370182
Name:BRAVO, DIEGO (DMD)
Entity type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:
Last Name:BRAVO
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:PO BOX 144100
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-4100
Mailing Address - Country:US
Mailing Address - Phone:787-878-5004
Mailing Address - Fax:787-878-5004
Practice Address - Street 1:164 CALLE DELFIN OLMO
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-4637
Practice Address - Country:US
Practice Address - Phone:787-878-5004
Practice Address - Fax:787-878-5004
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR25421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRJ043108OtherCRUZ AZUL
PR40679OtherTRIPLE S