1124377031 NPI number — EMERGENCY DENTAL & MAXILOFACIAL CARE CSP

Table of content: (NPI 1124377031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124377031 NPI number — EMERGENCY DENTAL & MAXILOFACIAL CARE CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERGENCY DENTAL & MAXILOFACIAL CARE 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:
1124377031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1388
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAGUAS
Provider Business Mailing Address State Name:
PUERTO RICO
Provider Business Mailing Address Postal Code:
00726
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
787-745-0708
Provider Business Mailing Address Fax Number:
787-747-9300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVE SABANA SECA
Provider Second Line Business Practice Location Address:
CARR 867 KM 2.2
Provider Business Practice Location Address City Name:
TOA BAJA
Provider Business Practice Location Address State Name:
PUERTO RICO
Provider Business Practice Location Address Postal Code:
00951
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
787-261-3260
Provider Business Practice Location Address Fax Number:
787-261-3260
Provider Enumeration Date:
09/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ BENITEZ
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-261-3260

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  000591 , 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: 3648 . This is a "REGISTRO EMERGENCY DENTAL" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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