Provider Demographics
NPI:1225161854
Name:IDENTAL CENTER, PROFESSIONAL DENTISTRY, CSP
Entity Type:Organization
Organization Name:IDENTAL CENTER, PROFESSIONAL DENTISTRY, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:CRISTINA
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-266-3140
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-1198
Mailing Address - Country:US
Mailing Address - Phone:787-266-3140
Mailing Address - Fax:787-893-3922
Practice Address - Street 1:URBANIZACION VILLA HILDA
Practice Address - Street 2:A5 STREET 1
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767
Practice Address - Country:US
Practice Address - Phone:787-266-3140
Practice Address - Fax:787-893-3922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty