=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912208166
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYRNA E CAMACHO DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2010
-----------------------------------------------------
Last Update Date | 02/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81 AVE ESMERALDA
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00969-4429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-485-4804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3431
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00970-3431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-485-4804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2865
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------