MEDICARE: CLINICA DENTAL CANTON MALL

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	1223G0001X	General Practice Dentistry	0982	PR

General Provider Information

NPI Number	:	1760711964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA DENTAL CANTON MALL

Provider Business Mailing Address
First Line	:	RIO HONDO AVE
Second Line	:	PMB SUITE 452
City	:	BAYAMON
State	:	PR
Zip	:	00961-3110
Country	:	US
Telephone Number	:	787-785-3170
Fax Number	:	787-785-3170

Provider Business Practice Location Address
First Line	:	RIO HONDO
Second Line	:	PMB SUITE 452
City	:	BAYAMON
State	:	PR
Zip	:	00961-3106
Country	:	US
Telephone Number	:	787-785-3170
Fax Number	:	787-785-3170

Authorized Official
Title or Position	:	CHIEF OF STAFF
Name	:	DR. JOSE ANTONIO AGUIRRE
Credential	:	D.M.D.
Telephone Number	:	787-785-3170

Provider Enumeration Date	:	12/17/2009
Last Update Date	:	12/17/2009

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