Provider Demographics
NPI:1235765983
Name:BOUTIQUE DENTAL
Entity Type:Organization
Organization Name:BOUTIQUE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-428-6363
Mailing Address - Street 1:URB ROYAL TOWN AVE LAS CUMBRES A20
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-428-6363
Mailing Address - Fax:787-799-5052
Practice Address - Street 1:URB ROYAL TOWN AVE LAS CUMBRES A20
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-428-6363
Practice Address - Fax:787-799-5052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty