Provider Demographics
NPI:1679976914
Name:PENUELAS DENTAL TEAM LLC
Entity Type:Organization
Organization Name:PENUELAS DENTAL TEAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:939-630-4102
Mailing Address - Street 1:PO BOX 801207
Mailing Address - Street 2:COTO LAUREL
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00780-1207
Mailing Address - Country:US
Mailing Address - Phone:787-836-3333
Mailing Address - Fax:787-836-1729
Practice Address - Street 1:628 PEDRO VELAZQUEZ
Practice Address - Street 2:EDIFICIO AURORA 3B
Practice Address - City:PENUELAS
Practice Address - State:PR
Practice Address - Zip Code:00624
Practice Address - Country:US
Practice Address - Phone:787-836-3333
Practice Address - Fax:787-836-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2851261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental