=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336575349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUARTE DENTAL CARE,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2013
-----------------------------------------------------
Last Update Date | 09/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 CALLE DUARTE SUITE 5B
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00917-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-630-8288
-----------------------------------------------------
Fax | 787-651-6683
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 CALLE DUARTE SUITE 5B
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00917-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-630-8288
-----------------------------------------------------
Fax | 787-651-6683
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. DIAZ RODRIGUEZ ERIKA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-487-5332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2868
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------