1093788663 NPI number — TRUJILLO DENTAL CLINIC

Table of content: (NPI 1093788663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093788663 NPI number — TRUJILLO DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRUJILLO DENTAL CLINIC
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:
1093788663
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:
CALLE DR. FERNANDEZ
Provider Second Line Business Mailing Address:
#206
Provider Business Mailing Address City Name:
TRUJILLO ALTO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-755-3045
Provider Business Mailing Address Fax Number:
787-292-0277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CALLE DR. FERNANDEZ
Provider Second Line Business Practice Location Address:
#206
Provider Business Practice Location Address City Name:
TRUJILLO ALTO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-755-3045
Provider Business Practice Location Address Fax Number:
787-292-0277
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VELAZQUEZ
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-755-3045

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  450 , 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)

  • Identifier: 42573TR . This is a "SSS PROVIDER ID" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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