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General NPI Number Information
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NPI Number | 1003168675
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Entity Type | Organization
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Legal Business Name | SAN PATRICIO DENTAL, LLC
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Dates
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Enumeration Date | 10/08/2012
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Last Update Date | 10/08/2012
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Provider Practice Location Address
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Address Line | 101 AVE SAN PATRICIO MARAMAR PLAZA SUITE 1210
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City | GUAYNABO
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State | PR
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Zip | 00968-2645
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Country | US
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Telephone | 787-565-0134
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Fax |
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Provider Business Mailing Address
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Address Line | 101 AVE SAN PATRICIO MARAMAR PLAZA SUITE 1210
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City | GUAYNABO
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State | PR
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Zip | 00968-2645
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ANABELLE M MUDAFORT
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Credential | DMD
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Telephone | 787-565-0134
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 2808
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2787
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License Number State | PR
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