Provider Demographics
NPI:1053681999
Name:GRUPO DENTAL DR. JOSE S BELAVAL
Entity Type:Organization
Organization Name:GRUPO DENTAL DR. JOSE S BELAVAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE SUB DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:MBH HCM
Authorized Official - Phone:787-480-3841
Mailing Address - Street 1:AVE BORINQUEN ESQ. CALLE NIN BO. OBRERO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AVE BORINQUEN ESQ. CALLE NIN BO. OBRERO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00915
Practice Address - Country:US
Practice Address - Phone:787-480-3841
Practice Address - Fax:787-977-0544
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CDT DR. JOSE S BELAVAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR400015Medicare PIN