Provider Demographics
NPI:1962262634
Name:DE SANTANA PEREIRA LOURENCO, POLLYANNA MARIA
Entity type:Individual
Prefix:MRS
First Name:POLLYANNA
Middle Name:MARIA
Last Name:DE SANTANA PEREIRA LOURENCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1079 S HIAWASSEE RD APT 1135
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-1734
Mailing Address - Country:US
Mailing Address - Phone:407-403-4041
Mailing Address - Fax:
Practice Address - Street 1:750 E 25TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3817
Practice Address - Country:US
Practice Address - Phone:407-403-4041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist