MEDICARE: MR. SANTIAGO P ROLDAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN15793	FL

General Provider Information

NPI Number	:	1932389913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SANTIAGO P ROLDAN DMD

Provider Business Mailing Address
First Line	:	1501 SE 23RD AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-7507
Country	:	US
Telephone Number	:	954-788-2388
Fax Number	:	954-785-3755

Provider Business Practice Location Address
First Line	:	1501 SE 23RD AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33062-7507
Country	:	US
Telephone Number	:	954-788-2388
Fax Number	:	954-785-3755

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2007
Last Update Date	:	02/20/2008

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