1003004714 NPI number — SERVICIOS ESPECIALIZADOS DE ORTODONCIA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003004714 NPI number — SERVICIOS ESPECIALIZADOS DE ORTODONCIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERVICIOS ESPECIALIZADOS DE ORTODONCIA
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:
1003004714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
OFFICE 12 65 INFANTERIA
Provider Second Line Business Mailing Address:
CENT COM LOS FLAMBOYANES
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00924-3314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
178-775-8156
Provider Business Mailing Address Fax Number:
178-775-8151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
OFFICE 12 65 INFANTERIA RIO PIEDRAS
Provider Second Line Business Practice Location Address:
CENT COM LOS FLAMBOYANES
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00924-3314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
178-775-8156
Provider Business Practice Location Address Fax Number:
178-775-8151
Provider Enumeration Date:
10/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ACEVEDO
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
17877581560

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  864 , 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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