Provider Demographics
NPI:1194025627
Name:PROGRAMA GRADUADO CIRUGIA ORAL Y MAXILOFACIAL, UPR
Entity Type:Organization
Organization Name:PROGRAMA GRADUADO CIRUGIA ORAL Y MAXILOFACIAL, UPR
Other - Org Name:ESCUELA DE MEDICINA DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ATILANO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-758-2525
Mailing Address - Street 1:PO BOX 365067
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-5067
Mailing Address - Country:US
Mailing Address - Phone:787-758-2525
Mailing Address - Fax:787-751-0858
Practice Address - Street 1:CENTRO MEDICO RIO PIEDRAS, RECINTO DE CIENCIAS MEDICAS
Practice Address - Street 2:1ER PISO, A 127
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936
Practice Address - Country:US
Practice Address - Phone:787-758-2525
Practice Address - Fax:787-751-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty