Healthcare Provider Details

I. General information

NPI: 1144300203
Provider Name (Legal Business Name): GRUPO DE ODONTOLOGIA COSMETICA Y ORTODONCIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 CALLE LUIS MUNOZ RIVERA
GUAYANILLA PR
00656-1717
US

IV. Provider business mailing address

PO BOX 560537
GUAYANILLA PR
00656-0537
US

V. Phone/Fax

Practice location:
  • Phone: 787-835-4014
  • Fax: 787-835-4014
Mailing address:
  • Phone: 787-835-4014
  • Fax: 787-835-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1827
License Number StatePR

VIII. Authorized Official

Name: DR. RAFAEL FRANCISCO DIAZ
Title or Position: PRESIDENT
Credential: DMD
Phone: 787-835-4014