Healthcare Provider Details

I. General information

NPI: 1689407785
Provider Name (Legal Business Name): PERIO DEL SUR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 AVE TITO CASTRO STE 810
PONCE PR
00716-4725
US

IV. Provider business mailing address

PO BOX 3171
MAYAGUEZ PR
00681-3171
US

V. Phone/Fax

Practice location:
  • Phone: 787-219-9032
  • Fax:
Mailing address:
  • Phone: 787-219-9032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. DIEGO E RODES
Title or Position: PRESIDENT
Credential: DDS
Phone: 787-219-9032