Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 0401415980 | VA |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 3315 | PR |
NPI | 1003104464 |
---|---|
Provider Name | Dr. Diego Alberto Gallardo |
First Address | Bayamon, PR 00957 |
Second Address | Guaynabo, PR 00969 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2011 |
Last Update Date | 29/09/2021 |