Provider Demographics
NPI:1285710228
Name:OLIVENCIA, EDGARDO E (DMD)
Entity type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:E
Last Name:OLIVENCIA
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:FLORENCIA ST. #E-12
Mailing Address - Street 2:EXT. VILLA CAPARRA
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-793-7175
Mailing Address - Fax:787-793-5539
Practice Address - Street 1:URB. SANFELIZ CALLE 5 #2
Practice Address - Street 2:
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-859-4514
Practice Address - Fax:787-793-5539
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics