Provider Demographics
NPI:1659465144
Name:FALLETTI, MARIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:FALLETTI
Suffix:
Gender:M
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 124
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-0124
Mailing Address - Country:US
Mailing Address - Phone:787-892-3672
Mailing Address - Fax:787-892-6909
Practice Address - Street 1:#62 DR VEVE
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:787-892-3672
Practice Address - Fax:787-892-6909
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRPR23691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR206286OtherPREFERED HEALTH
PR1192OtherIMC
PR041980OtherCRUZ AZUL
PR2369OtherLICENCIA DENTAL
PR42352OtherSSS
PR6230072OtherHUMANA
PR70141OtherPREFERED MEDICARE CHOICE