Provider Demographics
NPI:1437301140
Name:WESTERN COSMETIC ORAL AND MAXILLOFACIAL SURGERY CLINIC
Entity Type:Organization
Organization Name:WESTERN COSMETIC ORAL AND MAXILLOFACIAL SURGERY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:MUNIZ
Authorized Official - Last Name:LUCIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:787-833-1215
Mailing Address - Street 1:APARTADO 37
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:P.R.
Mailing Address - Zip Code:00681
Mailing Address - Country:UM
Mailing Address - Phone:787-833-1215
Mailing Address - Fax:787-265-0589
Practice Address - Street 1:27 NELSON PEREA ST.
Practice Address - Street 2:DOCTORS CENTER BLDNG. SUITE 206
Practice Address - City:MAYAGUEZ
Practice Address - State:P.R.
Practice Address - Zip Code:00680
Practice Address - Country:UM
Practice Address - Phone:787-833-1215
Practice Address - Fax:787-265-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PROTH000Medicare UPIN