Healthcare Provider Details

I. General information

NPI: 1609252121
Provider Name (Legal Business Name): OTIS ORTHODONTICS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

A7 URB SAN ANTONIO
HUMACAO PR
00791
US

IV. Provider business mailing address

PO BOX 758
HUMACAO PR
00792-0758
US

V. Phone/Fax

Practice location:
  • Phone: 787-285-5544
  • Fax:
Mailing address:
  • Phone: 787-285-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2708
License Number StatePR

VIII. Authorized Official

Name: DR. JOSE C VICENS
Title or Position: PRESIDENT
Credential: DMD
Phone: 787-633-6847