Provider Demographics
NPI:1710380316
Name:CASTELLO POLO, BLANCA MAIRENYS (DMD)
Entity Type:Individual
Prefix:DR
First Name:BLANCA
Middle Name:MAIRENYS
Last Name:CASTELLO POLO
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 1:6491 SUNSET STRIP STE 1
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33313-2867
Mailing Address - Country:US
Mailing Address - Phone:954-572-1801
Mailing Address - Fax:954-333-7561
Practice Address - Street 1:6491 SUNSET STRIP STE 1
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313-2867
Practice Address - Country:US
Practice Address - Phone:954-572-1801
Practice Address - Fax:954-333-7561
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-27
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist