Healthcare Provider Details

I. General information

NPI: 1265864961
Provider Name (Legal Business Name): JOSE ANTONIO VIVALDI-OLIVER DMD,MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALMIRANTE PINZON 242 EL VEDADO
SAN JUAN PR
00919
US

IV. Provider business mailing address

PO BOX 194796
SAN JUAN PR
00919-4796
US

V. Phone/Fax

Practice location:
  • Phone: 787-550-2160
  • Fax:
Mailing address:
  • Phone: 787-550-2160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number001523
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: