Provider Demographics
NPI:1972652162
Name:BERRIOS, AGNES LYNETTE (DMD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:LYNETTE
Last Name:BERRIOS
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 1:103 CALLE AUTONOMIA
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-3297
Mailing Address - Country:US
Mailing Address - Phone:787-876-2100
Mailing Address - Fax:
Practice Address - Street 1:103 CALLE AUTONOMIA
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729-3297
Practice Address - Country:US
Practice Address - Phone:787-876-2100
Practice Address - Fax:787-876-2100
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1281OtherDMD L ICENCE