=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083927818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRO AVANZADO DE ODONTOLOGIA ESTETICA,CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2010
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 CALLE BALDORIOTY N
-----------------------------------------------------
City | AIBONITO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00705-3234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-735-1741
-----------------------------------------------------
Fax | 787-735-1741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1378
-----------------------------------------------------
City | AIBONITO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00705-1378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-447-7078
-----------------------------------------------------
Fax | 787-735-1741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VICTOR RAFAEL ORTIZ
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-447-7078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1813
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------