=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578977369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OFICINA DENTAL DRA LAURA DEL FIERRO C LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CENTRO COMERCIAL VILLAS DE RIO GRANDE CALLE PIMENTEL PRIMER PISO
-----------------------------------------------------
City | RIO GRANDE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-887-3595
-----------------------------------------------------
Fax | 787-888-2007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5302 CALLE CERRILLO AA3 RIVER VALLEY TOWN PARK
-----------------------------------------------------
City | CANOVANAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-887-3595
-----------------------------------------------------
Fax | 888-988-1781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/PRESIDENT
-----------------------------------------------------
Name | DR. LAURA ALEJANDRA DEL FIERRO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-887-3595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2748
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------