=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578654158
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAUL A FONTANE DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PR 177 CORNER SANTA ANA ST CENTRO COMERCIAL ALTOMAR 2ND FL
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-720-9008
-----------------------------------------------------
Fax | 787-720-9007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PMB 226 1353 RD 19
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00966-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-720-9008
-----------------------------------------------------
Fax | 787-720-9007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS2312
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------