Healthcare Provider Details

I. General information

NPI: 1912174699
Provider Name (Legal Business Name): CENTRO PERIODONTAL DEL ESTE,CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HUMACAO MEDICAL PLAZA AVE. FONT MARTELO OFFIC 104
HUMACAO PR
00791
US

IV. Provider business mailing address

53 CALLE FONT MARTELO E OFICINA 104
HUMACAO PR
00791
US

V. Phone/Fax

Practice location:
  • Phone: 787-852-4475
  • Fax: 787-285-0632
Mailing address:
  • Phone: 787-852-4475
  • Fax: 787-285-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2009
License Number StatePR

VIII. Authorized Official

Name: DR. RAFAEL HERNANDEZ
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 787-852-4475