Healthcare Provider Details

I. General information

NPI: 1508117078
Provider Name (Legal Business Name): ADVANCE DENTAL JRJ,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE.SABANA SECA CARR 867 KM 2.2
TOA BAJA PR
00952
US

IV. Provider business mailing address

PO BOX 1388
CAGUAS PUERTO RICO
00726
UM

V. Phone/Fax

Practice location:
  • Phone: 787-261-3260
  • Fax: 787-261-3260
Mailing address:
  • Phone: 787-745-0708
  • Fax: 787-747-9300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number591
License Number StatePR

VIII. Authorized Official

Name: DR. JOSE M RODRIGUEZ BENITEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-745-0708