MEDICARE: CENTRO FAMILIAR DE SERVICIOS DENTALES, CSP

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

General Provider Information

NPI Number	:	1669700506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO FAMILIAR DE SERVICIOS DENTALES, CSP

Provider Business Mailing Address
First Line	:	PO BOX 201
Second Line	:
City	:	SAN SEBASTIAN
State	:	PR
Zip	:	00685-0201
Country	:	US
Telephone Number	:	787-896-1265
Fax Number	:	787-280-0171

Provider Business Practice Location Address
First Line	:	4100 AVE ARCADIO ESTRADA
Second Line	:	SUITE 110 SAN SEBASTIAN OFFICE BUILDING
City	:	SAN SEBASTIAN
State	:	PR
Zip	:	00685-3216
Country	:	US
Telephone Number	:	787-896-1265
Fax Number	:	787-280-0171

Authorized Official
Title or Position	:	DENTISTA
Name	:	DR. MARCIANO E. AVILES ROIG
Credential	:	D.M.D.
Telephone Number	:	787-896-1265

Provider Enumeration Date	:	12/04/2009
Last Update Date	:	12/04/2009

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