Healthcare Provider Details

I. General information

NPI: 1740574938
Provider Name (Legal Business Name): JOANNE BRACEROS CASTANEDA DDS, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2011
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 W MAIN RD
MIDDLETOWN RI
02842-4933
US

IV. Provider business mailing address

65 W MAIN RD
MIDDLETOWN RI
02842-4933
US

V. Phone/Fax

Practice location:
  • Phone: 401-848-0070
  • Fax:
Mailing address:
  • Phone: 401-848-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN03168
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: