Healthcare Provider Details

I. General information

NPI: 1689980682
Provider Name (Legal Business Name): JRC MAXILLOFACIAL SERVICES,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GARRIDO MORALES 53
FAJARDO PR
00738-1087
US

IV. Provider business mailing address

6 CALLE FLOR GERENA N
HUMACAO PR
00791-4293
US

V. Phone/Fax

Practice location:
  • Phone: 787-863-2549
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number995
License Number StatePR

VIII. Authorized Official

Name: DR. JUAN RAMON RIVERA
Title or Position: PRESIDENTE
Credential: DMD
Phone: 787-852-4685