Provider Demographics
NPI:1063489722
Name:PORTELA-VALES, JOSE M (DMD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:M
Last Name:PORTELA-VALES
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 1:751 CALLE SARDINA
Mailing Address - Street 2:SAN DEMETRIO
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-3511
Mailing Address - Country:US
Mailing Address - Phone:787-858-2066
Mailing Address - Fax:787-858-2066
Practice Address - Street 1:67 CALLE JOSE JULIAN ACOSTA
Practice Address - Street 2:
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-4436
Practice Address - Country:US
Practice Address - Phone:787-858-2066
Practice Address - Fax:787-858-2066
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice