Healthcare Provider Details

I. General information

NPI: 1639214018
Provider Name (Legal Business Name): MARIO POLO DMD,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 AVE FD ROOSEVELT 702 LA TORRE DE PLAZA
SAN JUAN PR
00918-8001
US

IV. Provider business mailing address

525 AVE FD ROOSEVELT 702 LA TORRE DE PLAZA
SAN JUAN PR
00918-8001
US

V. Phone/Fax

Practice location:
  • Phone: 787-754-7658
  • Fax: 787-753-8415
Mailing address:
  • Phone: 787-754-7658
  • Fax: 787-753-8415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD0806
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: