=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548853179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PDA MAXILLOFACIAL SURGERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2021
-----------------------------------------------------
Last Update Date | 02/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 CALLE ORTEGON SUITE 100 CAPARRA GALLERY PLAZA, AVE. GONZALEZ GIUSTI
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-425-0526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 366255
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00936-6255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-425-0526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DMD, PRESIDENT
-----------------------------------------------------
Name | DR. PATRICIA DEL PILAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-425-0526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------