=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619056603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CABO ROJO DENTAL GROUP, C.S.P.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 CALLE 25 DE JULIO
-----------------------------------------------------
City | GUANICA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00653-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-821-5222
-----------------------------------------------------
Fax | 787-821-5222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CALLE 25 DE JULIO NUM 22
-----------------------------------------------------
City | GUANICA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-821-5222
-----------------------------------------------------
Fax | 787-821-5222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DENNIS CABAN
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 787-831-2940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1216
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------