Healthcare Provider Details

I. General information

NPI: 1679618011
Provider Name (Legal Business Name): IBG PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUITE 202A, 107 AVE. GONZALEZ GUISTI
GUAYNABO PR
00966
US

IV. Provider business mailing address

22 CALLE J VILLA CAPARRA
GUAYNABO PR
00966-2203
US

V. Phone/Fax

Practice location:
  • Phone: 787-707-1977
  • Fax:
Mailing address:
  • Phone: 787-397-3644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberPR1927
License Number StatePR

VIII. Authorized Official

Name: DR. IRENE BANUCHI
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 787-707-1977