Provider Demographics
NPI:1740586916
Name:CONCEPTOS DENTALES DEL SUR
Entity Type:Organization
Organization Name:CONCEPTOS DENTALES DEL SUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-837-8667
Mailing Address - Street 1:4 CALLE SANTIAGO VEVE
Mailing Address - Street 2:
Mailing Address - City:JUANA DIAZ
Mailing Address - State:PR
Mailing Address - Zip Code:00795-1653
Mailing Address - Country:US
Mailing Address - Phone:787-837-8667
Mailing Address - Fax:787-837-9679
Practice Address - Street 1:4 CALLE SANTIAGO VEVE
Practice Address - Street 2:
Practice Address - City:JUANA DIAZ
Practice Address - State:PR
Practice Address - Zip Code:00795-1653
Practice Address - Country:US
Practice Address - Phone:787-837-8667
Practice Address - Fax:787-837-9679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRD2131261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental