=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346356375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAVIER JOSE GALLARDO DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 AVE COMERIO LEVITTOWN
-----------------------------------------------------
City | TOA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00949-4067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-784-8110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 CAMINO DEL MERLIN SABANERA
-----------------------------------------------------
City | DORADO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00646-3455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-460-5667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2529
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------