MEDICARE: DR. JULIO DEMETRIO GOYCO D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1055	PR

General Provider Information

NPI Number	:	1124102751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JULIO DEMETRIO GOYCO D.M.D

Provider Business Mailing Address
First Line	:	1757 CALLE SERENATA
Second Line	:	URB. MERCEDITA
City	:	PONCE
State	:	PR
Zip	:	00717-2608
Country	:	US
Telephone Number	:	787-843-2824
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 AVE LAS AMERICAS
Second Line	:	VILLA GRILLASCA
City	:	PONCE
State	:	PR
Zip	:	00717-0722
Country	:	US
Telephone Number	:	787-843-5526
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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