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General NPI Number Information
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NPI Number | 1295139707
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Entity Type | Organization
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Legal Business Name | DENTAL GALLERY PSC
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Dates
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Enumeration Date | 10/13/2014
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Last Update Date | 10/13/2014
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Provider Practice Location Address
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Address Line | MCS 466 AVE DE DIEGO 89 SUITE 105
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City | SAN JUAN
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State | PR
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Zip | 00927-5831
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Country | US
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Telephone | 787-361-0015
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Fax |
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Provider Business Mailing Address
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Address Line | MCS 466 AVE DE DIEGO 89 SUITE 105
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City | SAN JUAN
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State | PR
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Zip | 00927-5831
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Country | US
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Telephone | 787-361-0015
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ELISA M RIVERA
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Credential | D.M.D
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Telephone | 787-361-0015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2736
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License Number State | PR
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