Healthcare Provider Details

I. General information

NPI: 1518098110
Provider Name (Legal Business Name): GLORIA MILAGROS RODRIGUEZ PONSA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GLORIA MILAGROS RODRGUEZ PONSA DMD

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BAYAMON OESTE SHOPPING CENTER CARR. #2 HATO TEJAS SUITE #12
BAYAMON PR
00961
US

IV. Provider business mailing address

800 CALLE VESTA URB. DOS PINOS
SAN JUAN PR
00923-2342
US

V. Phone/Fax

Practice location:
  • Phone: 787-786-4133
  • Fax: 787-786-4133
Mailing address:
  • Phone: 787-292-9443
  • Fax: 787-786-4133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1386
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: