MEDICARE: INSTITUTO DENTAL DEL SUR.C.S.P.

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	1646	PR

General Provider Information

NPI Number	:	1114172681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTITUTO DENTAL DEL SUR.C.S.P.

Provider Business Mailing Address
First Line	:	54 CALLE MUNOZ RIVERA
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-1608
Country	:	US
Telephone Number	:	787-837-2314
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 CALLE MUNOZ RIVERA
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-1608
Country	:	US
Telephone Number	:	787-837-2314
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. INGRID M ROSSO-TRIDAS
Credential	:	D.M.D.
Telephone Number	:	787-837-2314

Provider Enumeration Date	:	11/24/2008
Last Update Date	:	11/24/2008

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