Provider Demographics
NPI:1508324880
Name:ALICEA CASTRO, MARIELYS NICOLE (DMD)
Entity Type:Individual
Prefix:
First Name:MARIELYS
Middle Name:NICOLE
Last Name:ALICEA CASTRO
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:VILLAS DE LA PLAYA
Mailing Address - Street 2:#174
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:VILLAS DE LA PLAYA
Practice Address - Street 2:#174
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:888-700-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR3349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program