Healthcare Provider Details

I. General information

NPI: 1912701376
Provider Name (Legal Business Name): PERIODONCIA DEL OESTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 04/03/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIFICIO MEDICOS DE DIEGO 14 E CALLE DE DIEGO
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 2896
MAYAGUEZ PR
00681-2896
US

V. Phone/Fax

Practice location:
  • Phone: 787-833-3548
  • Fax: 787-265-7788
Mailing address:
  • Phone: 787-833-3548
  • Fax: 787-265-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ALBERTO IVAN ALMODOVAR
Title or Position: PRESIDENTE
Credential: DMD
Phone: 787-833-3548