MEDICARE: OFICINA DENTAL LOS DOMINICOS, 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	305R00000X	Preferred Provider Organization	2242	PR

General Provider Information

NPI Number	:	1962726984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OFICINA DENTAL LOS DOMINICOS, PSC

Provider Business Mailing Address
First Line	:	AVE BOULEVARD, LOS DOMINICOS SHOPPING CENTER
Second Line	:	LOCAL 21-B
City	:	TOA BAJA
State	:	PR
Zip	:	00949-0000
Country	:	US
Telephone Number	:	787-787-0520
Fax Number	:

Provider Business Practice Location Address
First Line	:	AVE BOULEVARD, LOS DOMINICOS SHOPPING CENTER
Second Line	:	LOCAL 21 B , LEVITTOWN
City	:	TOA BAJA
State	:	PR
Zip	:	00949-0000
Country	:	US
Telephone Number	:	787-784-0520
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE
Name	:	MRS. EDMARIE DE JESUS
Credential	:	MRS
Telephone Number	:	787-784-0520

Provider Enumeration Date	:	03/19/2010
Last Update Date	:	03/19/2010

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