Healthcare Provider Details

I. General information

NPI: 1528304425
Provider Name (Legal Business Name): JANNELLY RESTITUYO ROSARIO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143-3 CALLE 401 VILLA CAROLINA
CAROLINA PR
00985-4022
US

IV. Provider business mailing address

143-3 CALLE 401 VILLA CAROLINA
CAROLINA PR
00985-4022
US

V. Phone/Fax

Practice location:
  • Phone: 787-200-5542
  • Fax: 787-200-5543
Mailing address:
  • Phone: 787-200-5542
  • Fax: 787-200-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2990
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: