Healthcare Provider Details

I. General information

NPI: 1013758994
Provider Name (Legal Business Name): JOSE L OLIVER SEGARRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 AVE ANDALUCIA
SAN JUAN PR
00920-5310
US

IV. Provider business mailing address

BDA MARIANI CALLE WILSON 1933
PONCE PR
00717
US

V. Phone/Fax

Practice location:
  • Phone: 787-626-6164
  • Fax:
Mailing address:
  • Phone: 787-420-9267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number003529
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2025052674
License Number StateMO
# 3
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: