Healthcare Provider Details

I. General information

NPI: 1609401942
Provider Name (Legal Business Name): INNOVARE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIF TROPICAL PLAZA SUITE 3 CARR 2 MARGINAL 272
HATILLO PR
00659
US

IV. Provider business mailing address

EDIF TROPICAL PLAZA SUITE 3 CARR 2 MARGINAL 272
HATILLO PR
00659
US

V. Phone/Fax

Practice location:
  • Phone: 787-690-2460
  • Fax:
Mailing address:
  • Phone: 787-690-2460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. TANIA DENISSE GONZALEZ FUENTES
Title or Position: DENTIST
Credential: DMD
Phone: 787-690-2460