MEDICARE: NOVA DENTAL LLC

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	:	1942126628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA DENTAL LLC

Provider Business Mailing Address
First Line	:	PO BOX 1104
Second Line	:
City	:	GURABO
State	:	PR
Zip	:	00778-1104
Country	:	US
Telephone Number	:	787-712-8857
Fax Number	:

Provider Business Practice Location Address
First Line	:	CARR 181 KM 22.9
Second Line	:	BO CELADA LOCAL 4 EDIF SOTERO GOMEZ
City	:	GURABO
State	:	PR
Zip	:	00778
Country	:	US
Telephone Number	:	787-712-8857
Fax Number	:

Authorized Official
Title or Position	:	DENTISTA
Name	:	REYNALDO ROSA
Credential	:	DMD
Telephone Number	:	787-712-8857

Provider Enumeration Date	:	06/26/2026
Last Update Date	:	06/26/2026

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