Provider Demographics
NPI:1790763548
Name:SANTIAGO, ENRIQUE A (DMD, MBA/HCM)
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:A
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:DMD, MBA/HCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8629 N JOHNNY MILLER DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-9795
Mailing Address - Country:US
Mailing Address - Phone:787-412-0021
Mailing Address - Fax:787-998-8464
Practice Address - Street 1:7225 N MONA LISA RD
Practice Address - Street 2:STE 203
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-4529
Practice Address - Country:US
Practice Address - Phone:520-888-0510
Practice Address - Fax:520-888-1688
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0085881223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4724OtherINTERNATIONAL MEDICAL CAR
PR1523449OtherTRICARE
PR40993OtherSSS