Healthcare Provider Details

I. General information

NPI: 1548853179
Provider Name (Legal Business Name): PDA MAXILLOFACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 02/15/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CALLE ORTEGON SUITE 100 CAPARRA GALLERY PLAZA, AVE. GONZALEZ GIUSTI
GUAYNABO PR
00966
US

IV. Provider business mailing address

PO BOX 366255
SAN JUAN PR
00936-6255
US

V. Phone/Fax

Practice location:
  • Phone: 787-425-0526
  • Fax:
Mailing address:
  • Phone: 787-425-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICIA DEL PILAR
Title or Position: DMD, PRESIDENT
Credential:
Phone: 787-425-0526