Provider Demographics
NPI:1174260491
Name:LASTRA CARRASQUILLO, JENNIFER (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:LASTRA CARRASQUILLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 10 BOX 49039
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-9654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2E19 AVE LUIS MUNOZ MARIN
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-6245
Practice Address - Country:US
Practice Address - Phone:787-692-8229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0034721223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program