Healthcare Provider Details

I. General information

NPI: 1033563150
Provider Name (Legal Business Name): MAIRYM Y DELGADO ROMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVE F D ROOSEVELT SUITE 506
SAN JUAN PR
00918
US

IV. Provider business mailing address

22 AVE SAN IGNACIO APT 302
GUAYNABO PR
00969-4306
US

V. Phone/Fax

Practice location:
  • Phone: 787-250-0907
  • Fax:
Mailing address:
  • Phone: 787-354-9186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3244
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: