Provider Demographics
NPI:1225078207
Name:SANTIAGO, ROBERTO
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ARREDONDO AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4573
Mailing Address - Country:US
Mailing Address - Phone:904-824-0990
Mailing Address - Fax:904-824-5898
Practice Address - Street 1:5 ARREDONDO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-4573
Practice Address - Country:US
Practice Address - Phone:904-824-0990
Practice Address - Fax:904-824-5898
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN136521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59-3725848OtherTAX ID