=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417318684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MG DENTAL CARE P.S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2016
-----------------------------------------------------
Last Update Date | 03/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 CALLE ELEONOR ROOSEVELT
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-2806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-763-9190
-----------------------------------------------------
Fax | 787-763-9587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 195015
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00919-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-763-9190
-----------------------------------------------------
Fax | 787-763-9587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARDILY GONZALEZ
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 787-763-9190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2658
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------