MEDICARE: CONCEPTOS DENTALES DEL SUR

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	261QD0000X	Dental Clinic/Center	D2131	PR

General Provider Information

NPI Number	:	1740586916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCEPTOS DENTALES DEL SUR

Provider Business Mailing Address
First Line	:	4 CALLE SANTIAGO VEVE
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-1653
Country	:	US
Telephone Number	:	787-837-8667
Fax Number	:	787-837-9679

Provider Business Practice Location Address
First Line	:	4 CALLE SANTIAGO VEVE
Second Line	:
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-1653
Country	:	US
Telephone Number	:	787-837-8667
Fax Number	:	787-837-9679

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DR. JORGE L RIVERA
Credential	:	DMD
Telephone Number	:	787-837-8667

Provider Enumeration Date	:	02/04/2011
Last Update Date	:	02/04/2011

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