Provider Demographics
NPI:1174666903
Name:SANTIAGO, MARIEDALI (DMD)
Entity Type:Individual
Prefix:
First Name:MARIEDALI
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1144
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-1144
Mailing Address - Country:US
Mailing Address - Phone:787-860-4088
Mailing Address - Fax:787-863-2441
Practice Address - Street 1:GENERAL VALERO
Practice Address - Street 2:311
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-860-4088
Practice Address - Fax:787-863-2441
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry