Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 045-R | PR |
NPI | 1568005296 |
---|---|
Provider Name | Erasmo Valladares |
First Address | San Juan, PR 00927-5313 |
Second Address | San Juan, PR 00927-5313 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2019 |
Last Update Date | 25/10/2019 |