Healthcare Provider Details

I. General information

NPI: 1184734683
Provider Name (Legal Business Name): JOSE ANTONIO SURIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ROOSEVELT AVE SUITE 502
SAN JUAN PR
00918
US

IV. Provider business mailing address

PO BOX 9022045
SAN JUAN PR
00902-2045
US

V. Phone/Fax

Practice location:
  • Phone: 787-756-5252
  • Fax:
Mailing address:
  • Phone: 787-724-7112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number626
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: