=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043217516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NELSON A PEREZ DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2005
-----------------------------------------------------
Last Update Date | 09/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE 54 BG 176 JARDINES DE RIO GRANDE
-----------------------------------------------------
City | RIO GRANDE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-887-7281
-----------------------------------------------------
Fax | 787-888-7008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CALLE LAUREL 2306 COND. THE TERRACE 10F
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-378-7275
-----------------------------------------------------
Fax | 787-657-2931
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2277
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------