Healthcare Provider Details

I. General information

NPI: 1295732147
Provider Name (Legal Business Name): PATRICIO J. SUMAZA, DMD, CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 AVE HOSTOS SUITE 211, MEDICAL EMPORIUM
MAYAGUEZ PR
00680-1502
US

IV. Provider business mailing address

351 AVE HOSTOS SUITE 211, MEDICAL EMPORIUM
MAYAGUEZ PR
00680-1502
US

V. Phone/Fax

Practice location:
  • Phone: 787-986-3636
  • Fax: 787-805-1610
Mailing address:
  • Phone: 787-986-3636
  • Fax: 787-805-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2496
License Number StatePR

VIII. Authorized Official

Name: DR. PATRICIO JAVIER SUMAZA
Title or Position: PRESIDENTE
Credential: DMD
Phone: 787-986-3636