Provider Demographics
NPI:1376918714
Name:CENTRO DE MICROENDODONCIA DE PUERTO RICO
Entity Type:Organization
Organization Name:CENTRO DE MICROENDODONCIA DE PUERTO RICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANNELLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-688-8389
Mailing Address - Street 1:500 AVE DEGETAU
Mailing Address - Street 2:HIMA PLAZA I SUITE 313
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-7301
Mailing Address - Country:US
Mailing Address - Phone:787-653-6210
Mailing Address - Fax:787-653-5846
Practice Address - Street 1:500 AVE DEGETAU
Practice Address - Street 2:HIMA PLAZA I SUITE 313
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-7301
Practice Address - Country:US
Practice Address - Phone:787-653-6210
Practice Address - Fax:787-653-5846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRGU636ZMedicare PIN