Healthcare Provider Details

I. General information

NPI: 1679625909
Provider Name (Legal Business Name): CIRUGIA ORAL Y MAXILOFACIAL CLA CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUITE 503 #400 FD AVE ROOSEVELT CLINICA LAS AMERICAS
HATO REY PR
00918
US

IV. Provider business mailing address

SUITE 503 #400 FD AVE ROOSEVELT CLINICA LAS AMERICAS
HATO REY PR
00918
US

V. Phone/Fax

Practice location:
  • Phone: 787-756-5300
  • Fax:
Mailing address:
  • Phone: 787-756-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number1699
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number2590
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number722
License Number StatePR

VIII. Authorized Official

Name: DR. JULIO E GUZMAN
Title or Position: PARTNER
Credential:
Phone: 787-756-5300