Healthcare Provider Details

I. General information

NPI: 1063919124
Provider Name (Legal Business Name): CENTRO DE RECONSTRUCCION ORAL E IMPLANTES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 1 ESQ 6 URB PARKSIDE COND SAN PATRICIO II SUITE 1
GUAYNABO PR
00968
US

IV. Provider business mailing address

PO BOX 361357
SAN JUAN PR
00936-1357
US

V. Phone/Fax

Practice location:
  • Phone: 787-781-1831
  • Fax: 787-781-5030
Mailing address:
  • Phone: 787-781-1831
  • Fax: 787-781-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StatePR

VIII. Authorized Official

Name: DR. JOSE E. PEDROZA RODRIGUEZ
Title or Position: PRESIDENTE
Credential:
Phone: 787-781-1831