=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740586916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCEPTOS DENTALES DEL SUR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2011
-----------------------------------------------------
Last Update Date | 02/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 CALLE SANTIAGO VEVE
-----------------------------------------------------
City | JUANA DIAZ
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00795-1653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-837-8667
-----------------------------------------------------
Fax | 787-837-9679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 CALLE SANTIAGO VEVE
-----------------------------------------------------
City | JUANA DIAZ
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00795-1653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-837-8667
-----------------------------------------------------
Fax | 787-837-9679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. JORGE L RIVERA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 787-837-8667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | D2131
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------