Healthcare Provider Details

I. General information

NPI: 1548927569
Provider Name (Legal Business Name): PRO ESTHETIC DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 CALLE DE LA CANDELARIA W STE 107
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

114 CALLE DE LA CANDELARIA W STE 107
MAYAGUEZ PR
00680
US

V. Phone/Fax

Practice location:
  • Phone: 787-265-3683
  • Fax:
Mailing address:
  • Phone: 787-265-3683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: NADYAN VARGAS
Title or Position: DMD
Credential: DMD
Phone: 787-265-3683