Provider Demographics
NPI:1093816555
Name:SEGARRA, EDWIN SR (DMD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:SEGARRA
Suffix:SR
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 8969
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-8969
Mailing Address - Country:US
Mailing Address - Phone:787-984-1529
Mailing Address - Fax:
Practice Address - Street 1:CALLE VILLA 129
Practice Address - Street 2:EDIFICIO CLAUSELLS SUITE 21
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-842-1027
Practice Address - Fax:787-842-1027
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093816555OtherMEDICAL CARD SYSTEM
PR1093816555OtherDELTA DENTAL
PR5925OtherFIRST PLUS
PR1789OtherCOOPERATIVA DE SEGUROS DE VIDA
41686OtherTRIPLE S INC
PR7320117OtherHUMANA HEALTH PLANS
PR26189OtherAMERICAN HEALTH
PR4298OtherINTERNATIONAL MEDICAL CAR
PR1093816555OtherMEDICARE DENTAL NETWORK
PR1093816555OtherMCS CLASICCARE
PR1093816555OtherTRLPE S MEDICARE ADVANTAGE