Healthcare Provider Details

I. General information

NPI: 1144813551
Provider Name (Legal Business Name): BAJALU, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 AVE GENERAL RAMEY STE 1
SAN ANTONIO PR
00690-1109
US

IV. Provider business mailing address

PO BOX 784
SAN ANTONIO PR
00690-0784
US

V. Phone/Fax

Practice location:
  • Phone: 787-510-0912
  • Fax:
Mailing address:
  • Phone: 787-510-0912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RAFAEL A. GAVILANES
Title or Position: VICE-PRESIDENTE
Credential: DMD
Phone: 787-510-0912