Healthcare Provider Details

I. General information

NPI: 1992907380
Provider Name (Legal Business Name): ORTODONCIA DEL NOROSESTE CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 107 KM 0 7 BO BARINQUEN
AGUADILLA PR
00603
US

IV. Provider business mailing address

PO BOX 4456
AGUADILLA PR
00605-4456
US

V. Phone/Fax

Practice location:
  • Phone: 787-891-0993
  • Fax: 787-891-7041
Mailing address:
  • Phone: 787-891-0993
  • Fax: 787-891-7041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2319
License Number StatePR

VIII. Authorized Official

Name: DR. JIMMARIE RAMOS FERNANDEZ
Title or Position: ORTHODONTIST
Credential: DMD
Phone: 787-891-0993