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General NPI Number Information
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NPI Number | 1144813551
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Entity Type | Organization
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Legal Business Name | BAJALU, LLC
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Dates
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Enumeration Date | 02/17/2021
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Last Update Date | 03/04/2021
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Provider Practice Location Address
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Address Line | 1005 AVE GENERAL RAMEY STE 1
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City | SAN ANTONIO
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State | PR
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Zip | 00690-1109
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Country | US
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Telephone | 787-510-0912
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 784
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City | SAN ANTONIO
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State | PR
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Zip | 00690-0784
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Country | US
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Telephone | 787-510-0912
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Fax |
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Authorized Official
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Title or Position | VICE-PRESIDENTE
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Name | DR. RAFAEL A. GAVILANES
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Credential | DMD
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Telephone | 787-510-0912
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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