Provider Demographics
NPI:1689407785
Name:PERIO DEL SUR LLC
Entity type:Organization
Organization Name:PERIO DEL SUR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:E
Authorized Official - Last Name:RODES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:787-219-9032
Mailing Address - Street 1:PO BOX 3171
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3171
Mailing Address - Country:US
Mailing Address - Phone:787-219-9032
Mailing Address - Fax:
Practice Address - Street 1:909 AVE TITO CASTRO STE 810
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4725
Practice Address - Country:US
Practice Address - Phone:787-219-9032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty