Healthcare Provider Details

I. General information

NPI: 1881203156
Provider Name (Legal Business Name): ALBA SANJUAN SANJUAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 09/25/2022
Certification Date: 09/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MORRIS ST STE 309
CHARLESTON WV
25301
US

IV. Provider business mailing address

415 MORRIS ST STE 309
CHARLESTON WV
25301-1853
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-3290
  • Fax: 304-388-3186
Mailing address:
  • Phone: 304-388-3290
  • Fax: 304-388-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4352000978
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number31823
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: