=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801156013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL SPA P.S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2012
-----------------------------------------------------
Last Update Date | 05/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 CALLE DEL PARQUE SUITE 1A
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00912-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-725-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1479 AVE ASHFORD COND. CONDADO DEL MAR APT # 410
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00907-1583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-725-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANGEL L DAVILA PABON
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 787-725-4848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2729
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------