Healthcare Provider Details

I. General information

NPI: 1033319538
Provider Name (Legal Business Name): THE PEDIATRIC DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 CHALAN SANTO PAPA STE 301
HAGATNA GU
96910
US

IV. Provider business mailing address

222 CHALAN SANTO PAPA STE 301
HAGATNA GU
96910
US

V. Phone/Fax

Practice location:
  • Phone: 671-477-6235
  • Fax: 671-477-6237
Mailing address:
  • Phone: 671-477-6235
  • Fax: 671-477-6237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD 992
License Number StateGU
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD 611
License Number StateGU

VIII. Authorized Official

Name: MS. BONIJEAN KEKOOLANI GARRIDO
Title or Position: BUSINESS MANAGER
Credential:
Phone: 671-477-6235