Provider Demographics
NPI:1689971731
Name:CLINICA DENTAL CDT GMSP, INC
Entity Type:Organization
Organization Name:CLINICA DENTAL CDT GMSP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-780-9196
Mailing Address - Street 1:URB SANTA CRUZ
Mailing Address - Street 2:B-7 CALLE SANTA CRUZ
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-780-9196
Mailing Address - Fax:
Practice Address - Street 1:URB SANTA CRUZ
Practice Address - Street 2:B-7 SANTA CRUZ ST
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-780-9196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CDT GMSP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-24
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR037582000Medicaid