Healthcare Provider Details

I. General information

NPI: 1568456192
Provider Name (Legal Business Name): RUBEN SARMIENTO SAGUN JR. D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MDG UNIT 3215
APO AE
09094-3215
US

IV. Provider business mailing address

86 MDG UNIT 3215
APO AE
09094-3215
US

V. Phone/Fax

Practice location:
  • Phone: 011496371462197
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number019-023382
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: