Provider Demographics
NPI:1013138973
Name:HERRERA, MARIO J (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:J
Last Name:HERRERA
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 30132
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00929-1132
Mailing Address - Country:US
Mailing Address - Phone:939-969-1255
Mailing Address - Fax:
Practice Address - Street 1:52 AVE BALDORIOTY W
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-3837
Practice Address - Country:US
Practice Address - Phone:787-738-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4350966OtherDRIVER LICENCE