Provider Demographics
NPI:1942487905
Name:POLHAMUS LOPEZ, MELISA (DMD)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:POLHAMUS LOPEZ
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:PO BOX 1863
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-1863
Mailing Address - Country:US
Mailing Address - Phone:787-615-1937
Mailing Address - Fax:
Practice Address - Street 1:CARR 172 KM 13.5
Practice Address - Street 2:AVE EL JIBARO
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739
Practice Address - Country:US
Practice Address - Phone:787-739-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR27911223G0001X
FLDN 203151223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice