Provider Demographics
NPI:1124247879
Name:URIBE, JUAN ANTONIO (DDS)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:ANTONIO
Last Name:URIBE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 S SAN PEDRO ST
Mailing Address - Street 2:#E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011
Mailing Address - Country:US
Mailing Address - Phone:213-747-8502
Mailing Address - Fax:
Practice Address - Street 1:2201 S SAN PEDRO ST
Practice Address - Street 2:#E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011
Practice Address - Country:US
Practice Address - Phone:213-747-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist