1225161854 NPI number — IDENTAL CENTER, PROFESSIONAL DENTISTRY, CSP

Table of content: (NPI 1225161854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225161854 NPI number — IDENTAL CENTER, PROFESSIONAL DENTISTRY, CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDENTAL CENTER, PROFESSIONAL DENTISTRY, CSP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225161854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1198
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS PIEDRAS
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00771-1198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-266-3140
Provider Business Mailing Address Fax Number:
787-893-3922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
URBANIZACION VILLA HILDA
Provider Second Line Business Practice Location Address:
A5 STREET 1
Provider Business Practice Location Address City Name:
YABUCOA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-266-3140
Provider Business Practice Location Address Fax Number:
787-893-3922
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
MAYRA
Authorized Official Middle Name:
CRISTINA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-266-3140

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2680 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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