=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588795314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MED VEC DENTAL CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | LAGUNA GARDENS SHOPPING CENTER SUITE 200
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-791-0906
-----------------------------------------------------
Fax | 787-791-6117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | LAGUNA GARDENS SHOPPING CENTER SUITE 200
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-791-0609
-----------------------------------------------------
Fax | 787-791-6117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | JEFE
-----------------------------------------------------
Name | DR. NORBERTO MEDINA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-791-0906
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1302
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------