=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083776397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS A FRAGUADA-VEGA DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | B28 CALLE CORAZON VILLA CRIOLLOS
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-745-2130
-----------------------------------------------------
Fax | 787-745-2130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 363861
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00936-3861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-745-2130
-----------------------------------------------------
Fax | 787-745-2130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2763
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------