=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881984920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MPL MAXILLOFACIAL SURGERY, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2011
-----------------------------------------------------
Last Update Date | 06/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 111 KM 18 BAHOMAMEY
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-232-5590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1678
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685-1678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MIGUEL PASTRANA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-232-5590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 2043
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------