Provider Demographics
NPI:1831224294
Name:MARRERO GRATACOS, JUAN CARLOS
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:MARRERO GRATACOS
Suffix:
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:CALLE 1326 STE 107
Mailing Address - Street 2:EL SENORIAL PLAZA
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717
Mailing Address - Country:US
Mailing Address - Phone:787-812-1010
Mailing Address - Fax:
Practice Address - Street 1:1326 STE 107
Practice Address - Street 2:EL SENORIAL PLZ
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1686
Practice Address - Country:US
Practice Address - Phone:787-812-1010
Practice Address - Fax:787-675-4596
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRD24641223G0001X
FLM662-423-73-146-01223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1831224294Medicaid