Healthcare Provider Details

I. General information

NPI: 1285710228
Provider Name (Legal Business Name): EDGARDO E OLIVENCIA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB. SANFELIZ CALLE 5 #2
COROZAL PR
00784
US

IV. Provider business mailing address

FLORENCIA ST. #E-12 EXT. VILLA CAPARRA
GUAYNABO PR
00966
US

V. Phone/Fax

Practice location:
  • Phone: 787-859-4514
  • Fax: 787-793-5539
Mailing address:
  • Phone: 787-793-7175
  • Fax: 787-793-5539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number876
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: