Healthcare Provider Details

I. General information

NPI: 1720084239
Provider Name (Legal Business Name): JAIME L MALDONADO-MOLL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#249 AVENUE EMILIANO POL URB. LA CUMBRE
SAN JUAN PR
00926-5639
US

IV. Provider business mailing address

497 AVE EMILIANO POL
SAN JUAN PR
00926-5602
US

V. Phone/Fax

Practice location:
  • Phone: 787-720-0677
  • Fax: 787-720-3266
Mailing address:
  • Phone: 787-720-0677
  • Fax: 787-720-0677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1224
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: