Healthcare Provider Details

I. General information

NPI: 1710355979
Provider Name (Legal Business Name): SAN JUAN PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 CALLE PONCE PEREZ MORRIS
SAN JUAN PR
00917-5021
US

IV. Provider business mailing address

6 CALLE PONCE PEREZ MORRIS
SAN JUAN PR
00917-5021
US

V. Phone/Fax

Practice location:
  • Phone: 787-281-6681
  • Fax: 787-250-1392
Mailing address:
  • Phone: 787-281-6681
  • Fax: 787-250-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MR. JUAN RAFAEL SILVA
Title or Position: PRESIDENT
Credential: MD
Phone: 787-281-6681