Provider Demographics
NPI:1053884338
Name:BERLANGA, JUAN EDWARD (LD)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:EDWARD
Last Name:BERLANGA
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 N ROCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-1724
Mailing Address - Country:US
Mailing Address - Phone:253-777-8339
Mailing Address - Fax:
Practice Address - Street 1:654 N ROCHESTER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-1724
Practice Address - Country:US
Practice Address - Phone:253-777-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN60041183122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist