Provider Demographics
NPI:1124144720
Name:VALLES NEVAREZ, EDGARDO LUIS (DMD)
Entity type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:LUIS
Last Name:VALLES NEVAREZ
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 1:1057 CALLE 8
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-5221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SUITE 5 MARIA DEL CARMEN PLAZA
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-859-7575
Practice Address - Fax:787-859-6565
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR25801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7719Medicare UPIN
PR2061095Medicare UPIN
PR7830021Medicare UPIN
PR40685Medicare UPIN
PR043114Medicare UPIN