Provider Demographics
NPI:1528427663
Name:RIOS, JUAN CARLOS (DDS)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:RIOS
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 1:3795 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3631
Mailing Address - Country:US
Mailing Address - Phone:619-220-0548
Mailing Address - Fax:619-220-8604
Practice Address - Street 1:3795 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-3631
Practice Address - Country:US
Practice Address - Phone:619-220-0548
Practice Address - Fax:619-220-8604
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65358122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA65358OtherDENTAL LICENSE