=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487861704
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTALIA MEDIKA CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 857 0.4 BO CANOVANILLAS
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-776-3840
-----------------------------------------------------
Fax | 787-276-2923
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 800
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00986-0800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-776-3840
-----------------------------------------------------
Fax | 787-276-2923
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DUENO
-----------------------------------------------------
Name | DR. RAFAEL ORTIZ PIETRI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-776-3840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------