Provider Demographics
NPI:1013903996
Name:BURGOS POLO, JOSE RICARDO (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RICARDO
Last Name:BURGOS POLO
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 1:110 MOLLER WAY
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2867
Mailing Address - Country:US
Mailing Address - Phone:863-660-5401
Mailing Address - Fax:
Practice Address - Street 1:37944 PASCO AVE
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-4202
Practice Address - Country:US
Practice Address - Phone:352-518-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR02586122300000X
FLDTC181223G0001X
FLDN27318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003690900Medicaid
PR7082OtherINTERNATIONAL MEDICAL CAR
PR41079BUOtherSSS PROVIDER
PR70338AOtherPREFERED MEDICAL CHOICE
PR660427801F3OtherMCS ADVANTAGE
FLDTC18OtherFLORIDA DENTAL TEMPORARY CERTIFICATE
FLDTC-168OtherFLORIDA STATE DENTAL TEMPORARY CERTIFICATE