Provider Demographics
NPI:1851480834
Name:GRUPO DENTAL CORDOVA CSP
Entity Type:Organization
Organization Name:GRUPO DENTAL CORDOVA CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-780-6261
Mailing Address - Street 1:CALLE 25 DD-16
Mailing Address - Street 2:RIVERVIEW
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-780-6261
Mailing Address - Fax:
Practice Address - Street 1:DD16 CALLE 25
Practice Address - Street 2:RIVERVIEW
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-3804
Practice Address - Country:US
Practice Address - Phone:787-780-6261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR987122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty