Basic Information
| Provider Information | |||||||||
| NPI: | 1972652162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRIOS | ||||||||
| FirstName: | AGNES | ||||||||
| MiddleName: | LYNETTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 103 CALLE AUTONOMIA | ||||||||
| Address2: | |||||||||
| City: | CANOVANAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007293297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878762100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 CALLE AUTONOMIA | ||||||||
| Address2: | |||||||||
| City: | CANOVANAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007293297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878762100 | ||||||||
| FaxNumber: | 7878762100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 1281 | PR | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1281 | 01 | PR | DMD L ICENCE | OTHER |