Healthcare Provider Details

I. General information

NPI: 1255189478
Provider Name (Legal Business Name): JORGE ENRIQUE COLOM DIEZ DMD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 09/11/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB HIGHLAND GARDEN A1 CALLE ARPEGIO
GUAYNABO PR
00969
US

IV. Provider business mailing address

126 CALLE BIZMARKIA
GUAYNABO PR
00969-5816
US

V. Phone/Fax

Practice location:
  • Phone: 787-789-6400
  • Fax:
Mailing address:
  • Phone: 939-639-8629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3557
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: