=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649607417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL WORLD CLINIC L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2013
-----------------------------------------------------
Last Update Date | 12/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 CALLE DR RUFO
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-747-1035
-----------------------------------------------------
Fax | 787-747-1035
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 CALLE DR RUFO
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-747-1035
-----------------------------------------------------
Fax | 787-747-1035
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GIL ALBERTO DIAZ
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 787-206-2839
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------