MEDICARE: SAN JUAN ENDODONTICS PSC

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	261QD0000X	Dental Clinic/Center	2008	PR

General Provider Information

NPI Number	:	1336544857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JUAN ENDODONTICS PSC

Provider Business Mailing Address
First Line	:	1738 AMARILLO ST.
Second Line	:	BOX 16
City	:	SAN JUAN
State	:	PR
Zip	:	00926
Country	:	US
Telephone Number	:	787-765-7248
Fax Number	:

Provider Business Practice Location Address
First Line	:	1738 CALLE AMARILLO
Second Line	:	SUITE 207-B (BOX 16)
City	:	SAN JUAN
State	:	PR
Zip	:	00926-3072
Country	:	US
Telephone Number	:	787-765-7248
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. JOSE AGUSTIN MEDINA
Credential	:	DMD
Telephone Number	:	787-765-7248

Provider Enumeration Date	:	10/27/2014
Last Update Date	:	10/27/2014

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