=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164293726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEL PARQUE DENTAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2024
-----------------------------------------------------
Last Update Date | 09/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 171 CALLE DEL PARQUE
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00911-1968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-723-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 67 BOX 15090
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00956-9510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DENISHA BERRIOS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-664-0935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------