=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023187010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MERCEDES FUSTE DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 09/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 INF. AVE. K3 H4 SAN JUAN AGING CENTER
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-480-5402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 579 CALLE GARFIELD
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926-5615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-653-2377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D 1422
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------