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General NPI Number Information
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NPI Number | 1689043531
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Entity Type | Organization
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Legal Business Name | CAVITY REPAIR LLC
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Dates
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Enumeration Date | 09/22/2015
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Last Update Date | 09/22/2015
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Provider Practice Location Address
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Address Line | 557B CALLE JULIAN RIVERA
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City | CEIBA
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State | PR
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Zip | 00735
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Country | US
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Telephone | 787-885-0560
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Fax | 787-885-0560
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Provider Business Mailing Address
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Address Line | 557B JULIAN RIVERA
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City | CEIBA
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State | PR
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Zip | 00735
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Country | US
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Telephone | 787-885-0560
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Fax | 787-885-0560
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDWIN E LAFONTAINE
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Credential |
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Telephone | 787-515-7036
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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 | 2080
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License Number State | PR
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