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General NPI Number Information
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NPI Number | 1679976914
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Entity Type | Organization
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Legal Business Name | PENUELAS DENTAL TEAM LLC
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Dates
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Enumeration Date | 10/01/2014
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Last Update Date | 10/01/2014
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Provider Practice Location Address
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Address Line | 628 PEDRO VELAZQUEZ EDIFICIO AURORA 3B
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City | PENUELAS
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State | PR
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Zip | 00624
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Country | US
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Telephone | 787-836-3333
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Fax | 787-836-1729
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Provider Business Mailing Address
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Address Line | PO BOX 801207 COTO LAUREL
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City | PONCE
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State | PR
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Zip | 00780-1207
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Country | US
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Telephone | 787-836-3333
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Fax | 787-836-1729
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. IVAN TORRES
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Credential | D.M.D.
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Telephone | 939-630-4102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2851
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License Number State | PR
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