Healthcare Provider Details

I. General information

NPI: 1386638088
Provider Name (Legal Business Name): GUSTAVO FADHEL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SAN JUAN CITY HOSPITAL MEDICAL CENTER
SAN JUAN PR
00936
US

IV. Provider business mailing address

LUIS MUNOZ MARIN AVE. STE 206 QUADRANGLE MEDICAL CENTER
CAGUAS PR
00725
US

V. Phone/Fax

Practice location:
  • Phone: 787-766-2223
  • Fax:
Mailing address:
  • Phone: 787-746-0895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1685
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: