Healthcare Provider Details

I. General information

NPI: 1457356180
Provider Name (Legal Business Name): PATRICIO JAVIER SUMAZA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 AVE HOSTOS STE 211
MAYAGUEZ PR
00680-1503
US

IV. Provider business mailing address

351 AVE HOSTOS
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:
Title or Position:
Credential:
Phone: