Healthcare Provider Details

I. General information

NPI: 1962685701
Provider Name (Legal Business Name): CENTRO DE PERIODONCIA E IMPLANTES DE PR,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2007
Last Update Date: 12/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 AVE SAN PATRICIO MARAMAR PLAZA STE. 830
GUAYNABO PR
00968-2645
US

IV. Provider business mailing address

101 AVE SAN PATRICIO MARAMAR PLAZA STE. 830
GUAYNABO PR
00968-2645
US

V. Phone/Fax

Practice location:
  • Phone: 787-781-2737
  • Fax: 787-783-7320
Mailing address:
  • Phone: 787-781-2737
  • Fax: 787-783-7320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2577
License Number StatePR

VIII. Authorized Official

Name: DR. REINALDO ROSAS
Title or Position: PRESIDENT
Credential: D.M.D.,M.S.
Phone: 787-781-2737