=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285878587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMUM DENTAL CARE, CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2009
-----------------------------------------------------
Last Update Date | 04/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 AVE ORTEGON STE 202 CAPARRA GALLERY BUILDING
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00966-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-783-6698
-----------------------------------------------------
Fax | 787-793-3105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 AVE ORTEGON STE 202 CAPARRA GALLERY BUILDING
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00966-2517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-783-6698
-----------------------------------------------------
Fax | 787-793-3105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ITHAMAR CASTRO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-783-6698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 2239
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------