Healthcare Provider Details

I. General information

NPI: 1992893515
Provider Name (Legal Business Name): MARISEL CASASNOVAS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 11/10/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 AVE. LAS CUMBRES LAS VISTAS SHOPPING VILLAGE, SUITE 40
SAN JUAN PR
00926
US

IV. Provider business mailing address

1738 CALLE AMARILLO SUITE 207-A
SAN JUAN PR
00926-3072
US

V. Phone/Fax

Practice location:
  • Phone: 787-680-7385
  • Fax: 787-680-7386
Mailing address:
  • Phone: 787-281-0614
  • Fax: 787-281-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1982
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: