MEDICARE: PROGRAMA GRADUADO EN ODONOLOGIA GENERAL GPR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1053770875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRAMA GRADUADO EN ODONOLOGIA GENERAL GPR

Provider Business Mailing Address
First Line	:	PO BOX 365067
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00936-5067
Country	:	US
Telephone Number	:	787-758-2525
Fax Number	:	787-641-1181

Provider Business Practice Location Address
First Line	:	MEDICAL SCIENCES CAMPUS DR. GUILLERMO ARBONA BUILDING
Second Line	:	BARRIO MONACILLOS OFFICE A163 SAN JUAN, PUERTO RICO
City	:	SAN JUAN
State	:	PR
Zip	:	00936-9998
Country	:	US
Telephone Number	:	787-758-2525
Fax Number	:	787-641-1181

Authorized Official
Title or Position	:	SECRETARIA ADMINISTRATIVA
Name	:	MRS. DORIS M GARCIA
Credential	:
Telephone Number	:	787-758-2525

Provider Enumeration Date	:	02/22/2016
Last Update Date	:	02/22/2016

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