Healthcare Provider Details

I. General information

NPI: 1861851768
Provider Name (Legal Business Name): JEAN MARIE SANJURJO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 CLOVE RD
STATEN ISLAND NY
10301-4338
US

IV. Provider business mailing address

290 SUMMIT AVE
SUMMIT NJ
07901-2207
US

V. Phone/Fax

Practice location:
  • Phone: 718-273-1101
  • Fax:
Mailing address:
  • Phone: 917-716-7812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number084010512
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: