Provider Demographics
NPI:1609252121
Name:OTIS ORTHODONTICS PSC
Entity Type:Organization
Organization Name:OTIS ORTHODONTICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:C
Authorized Official - Last Name:VICENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-633-6847
Mailing Address - Street 1:PO BOX 758
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792-0758
Mailing Address - Country:US
Mailing Address - Phone:787-285-5544
Mailing Address - Fax:
Practice Address - Street 1:A7 URB SAN ANTONIO
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-285-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2708261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental