Healthcare Provider Details

I. General information

NPI: 1326010448
Provider Name (Legal Business Name): EDWIN ALBERTO DEL VALEE SEPULVEDA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: EDWIN DEL VALLE SEPULVEDA DMD

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 PONCE BY PASS SUITE 605 PARNA MEDICAL INSTITUTE
PONCE PR
00717-1322
US

IV. Provider business mailing address

F 5 LA CASA BLANCA ST PASEO SAN JUAN
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-841-7892
  • Fax: 787-259-7514
Mailing address:
  • Phone: 787-286-9025
  • Fax: 787-743-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1553
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: