Healthcare Provider Details

I. General information

NPI: 1235936550
Provider Name (Legal Business Name): BURGOS DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2025
Last Update Date: 02/25/2025
Certification Date: 02/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PR-172 INT. PR-1 PLAZA DEL CARMEN MALL, SUITE 22
SAN JUAN PR
00922
US

IV. Provider business mailing address

PO BOX 10818
SAN JUAN PR
00922-0818
US

V. Phone/Fax

Practice location:
  • Phone: 787-745-6220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: JOSE BURGOS DIAZ
Title or Position: PRESIDENT
Credential:
Phone: 609-246-8000