Healthcare Provider Details

I. General information

NPI: 1952747545
Provider Name (Legal Business Name): PISHADENT,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CALLE JARDINES S-1
PONCE PR
00730-3547
US

IV. Provider business mailing address

JARDINES FAGOT 15 S-1
PONCE PR
00716
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-3435
  • Fax:
Mailing address:
  • Phone: 787-840-3435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2871
License Number StatePR

VIII. Authorized Official

Name: MISS ROLON E GLENDA
Title or Position: ASSISTANT
Credential: O
Phone: 787-630-8288