Provider Demographics
NPI:1265539837
Name:CORREA AGOSTO, MARITZA (DMD)
Entity type:Individual
Prefix:DR
First Name:MARITZA
Middle Name:
Last Name:CORREA AGOSTO
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 368015
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-8815
Mailing Address - Country:US
Mailing Address - Phone:787-378-3599
Mailing Address - Fax:
Practice Address - Street 1:667 CALLE LA PAZ STE 101
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-723-9947
Practice Address - Fax:787-723-9947
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice