Provider Demographics
NPI:1427181841
Name:TOA ALTA DENTAL GROUP CORPORATE
Entity Type:Organization
Organization Name:TOA ALTA DENTAL GROUP CORPORATE
Other - Org Name:TOA ALTA DENTAL GROUP P.S.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:MARCOS
Authorized Official - Last Name:VELAZQUEZ RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DENTAL ADMINISTRATIO
Authorized Official - Phone:787-870-1425
Mailing Address - Street 1:PO BOX 1295
Mailing Address - Street 2:PO BOX 1295
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00954-1295
Mailing Address - Country:US
Mailing Address - Phone:787-870-1425
Mailing Address - Fax:787-870-5934
Practice Address - Street 1:15 CALLE MUNOZ RIVERA (ALTOS)
Practice Address - Street 2:CALLE MUNOZ RIVERA 15
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-870-1425
Practice Address - Fax:787-870-5934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR55141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1083642029Medicare UPIN
PR1871544908Medicare UPIN
PR1114006079Medicare UPIN
PR1891850368Medicare UPIN