Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 00942 | PR |
NPI | 1144426461 |
---|---|
Provider Name | Humberto Villa |
First Address | Arecibo, PR 00612-4383 |
Second Address | Arecibo, PR 00612-4383 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2007 |
Last Update Date | 08/07/2007 |