Healthcare Provider Details

I. General information

NPI: 1871042325
Provider Name (Legal Business Name): DENTISTAS MISIONEROS DE PR (DMDPR)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE WILLIAM FONT FINAL CLINICA DENTAL CDT CULEBRA
CULEBRA PR
00775
US

IV. Provider business mailing address

58 CALLE MANUEL CRUZ
HUMACAO PR
00791-3627
US

V. Phone/Fax

Practice location:
  • Phone: 787-742-0001
  • Fax: 787-742-0176
Mailing address:
  • Phone: 787-852-1579
  • Fax: 787-852-8255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2452
License Number StatePR

VIII. Authorized Official

Name: DR. LILIAM ORTIZ
Title or Position: PRESIDENT
Credential: DMD
Phone: 787-852-8255