Provider Demographics
NPI:1346362928
Name:C L A DENTAL GROUP
Entity Type:Organization
Organization Name:C L A DENTAL GROUP
Other - Org Name:ADVANCED DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:H
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:787-753-5055
Mailing Address - Street 1:735 AVE PONCE DE LEON STE 504
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-5026
Mailing Address - Country:US
Mailing Address - Phone:787-753-5055
Mailing Address - Fax:
Practice Address - Street 1:735 AVE PONCE DE LEON STE 504
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-5026
Practice Address - Country:US
Practice Address - Phone:787-753-5055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13181223E0200X
PR15861223G0001X
PR27721223G0001X
PR27161223G0001X
PR21011223G0001X
PR18041223G0001X
PR22391223P0221X
PR06261223P0300X
PR24441223P0300X
PR17871223X0400X
PR02661223X0400X
PR24541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty