=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093816555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWIN SEGARRA SR. DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 04/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE VILLA 129 EDIFICIO CLAUSELLS SUITE 21
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-842-1027
-----------------------------------------------------
Fax | 787-842-1027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8969
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00732-8969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-984-1529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1789
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------