=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538715404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LRC ESTHETIC DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 576 CALLE CESAR GONZALEZ STE 301
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-773-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6063
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00726-6063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-773-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LILLIAM EDITH RIVERA CAMACHO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-773-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------