Healthcare Provider Details

I. General information

NPI: 1700299104
Provider Name (Legal Business Name): GRUPO DENTAL PEDIATRICO SAN JUAN CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 AVE CESAR GONZALEZ SUITE 307 GRUPO DENTAL PEDIATRICO DORAL BANK CENTER
SAN JUAN PR
00918-0000
US

IV. Provider business mailing address

576 AVE CESAR GONZALEZ SUITE 307 GRUPO DENTAL PEDIATRICO DORAL BANK CENTER
SAN JUAN PR
00918-0000
US

V. Phone/Fax

Practice location:
  • Phone: 787-753-1405
  • Fax: 787-753-1475
Mailing address:
  • Phone: 787-753-1405
  • Fax: 787-753-1475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2767
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2472
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2841
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number618
License Number StatePR

VIII. Authorized Official

Name: MRS. YILDA M RIVERA I
Title or Position: PRESIDENT
Credential: DMD
Phone: 787-753-1475