Provider Demographics
NPI:1558703942
Name:PR DENTAL PHOENIX PSC
Entity Type:Organization
Organization Name:PR DENTAL PHOENIX PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BELTRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-616-8557
Mailing Address - Street 1:267 CALLE SIERRA MORENA
Mailing Address - Street 2:PMB 627
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5574
Mailing Address - Country:US
Mailing Address - Phone:787-616-8557
Mailing Address - Fax:
Practice Address - Street 1:267 CALLE SIERRA MORENA
Practice Address - Street 2:PMB 627
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-5574
Practice Address - Country:US
Practice Address - Phone:787-616-8557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty