Provider Demographics
NPI:1568841484
Name:JARUCO DENTAL SERVICES CSP
Entity Type:Organization
Organization Name:JARUCO DENTAL SERVICES CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVELISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ REVERON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-866-3631
Mailing Address - Street 1:24 CALLE SANTIAGO PALMER SUR
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00784
Mailing Address - Country:US
Mailing Address - Phone:787-866-3631
Mailing Address - Fax:787-866-8690
Practice Address - Street 1:24 CALLE SANTIAGO PALMER SUR
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-866-3631
Practice Address - Fax:787-866-8690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1659379303Medicare PIN