Healthcare Provider Details

I. General information

NPI: 1093637928
Provider Name (Legal Business Name): FAMILY DENTAL PR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 AVE LOS CORAZONES STE 204
MAYAGUEZ PR
00680-7064
US

IV. Provider business mailing address

1065 AVE LOS CORAZONES STE 204
MAYAGUEZ PR
00680-7064
US

V. Phone/Fax

Practice location:
  • Phone: 787-208-9332
  • Fax:
Mailing address:
  • Phone: 787-208-9332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. GRISEL MARTIR MORENO
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-833-5917