Provider Demographics
NPI:1801941422
Name:IRAVEDRA, MANUEL LUIS (DMD, BSPH)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:LUIS
Last Name:IRAVEDRA
Suffix:
Gender:M
Credentials:DMD, BSPH
Other - Prefix:
Other - First Name:MANUEL
Other - Middle Name:LUIS
Other - Last Name:IRAVEDRA GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD, BSPH
Mailing Address - Street 1:1814 CALLE GLASGOW
Mailing Address - Street 2:COLLEGE PARK
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-4814
Mailing Address - Country:US
Mailing Address - Phone:787-758-8510
Mailing Address - Fax:
Practice Address - Street 1:PO BOX PH
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503-8000
Practice Address - Country:US
Practice Address - Phone:928-674-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2750183500000X
PRD13881223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No183500000XPharmacy Service ProvidersPharmacist