Healthcare Provider Details

I. General information

NPI: 1205642626
Provider Name (Legal Business Name): EDGE ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 AVE JESUS T PINERO STE 103
SAN JUAN PR
00921-1100
US

IV. Provider business mailing address

1910 AVE JESUS T PINERO STE 103
SAN JUAN PR
00921-1100
US

V. Phone/Fax

Practice location:
  • Phone: 787-427-9211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: NICOLLE CELESTE REYES MELENDEZ
Title or Position: PRESIDENT
Credential:
Phone: 787-367-2067