Provider Demographics
NPI:1124377031
Name:EMERGENCY DENTAL & MAXILOFACIAL CARE CSP
Entity Type:Organization
Organization Name:EMERGENCY DENTAL & MAXILOFACIAL CARE CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODRIGUEZ BENITEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-261-3260
Mailing Address - Street 1:PO BOX 1388
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00726
Mailing Address - Country:UM
Mailing Address - Phone:787-745-0708
Mailing Address - Fax:787-747-9300
Practice Address - Street 1:AVE SABANA SECA
Practice Address - Street 2:CARR 867 KM 2.2
Practice Address - City:TOA BAJA
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00951
Practice Address - Country:UM
Practice Address - Phone:787-261-3260
Practice Address - Fax:787-261-3260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000591122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3648OtherREGISTRO EMERGENCY DENTAL