Provider Demographics
NPI:1841049418
Name:SOTO DIEZ, IAN JOSE (DDS)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:JOSE
Last Name:SOTO DIEZ
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 1:50 AVE LUIS MUNOZ MARIN STE 302
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-3981
Mailing Address - Country:US
Mailing Address - Phone:787-361-7775
Mailing Address - Fax:
Practice Address - Street 1:50 AVE LUIS MUNOZ MARIN STE 302
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-3981
Practice Address - Country:US
Practice Address - Phone:787-361-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR35351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program