Provider Demographics
NPI:1942503792
Name:CLINICA DENTAL DRA. CARLA FIDALGO,CSP
Entity Type:Organization
Organization Name:CLINICA DENTAL DRA. CARLA FIDALGO,CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIDALGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-270-1417
Mailing Address - Street 1:MIRABELLA VILLAGE D76
Mailing Address - Street 2:AMATISTA ST.
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-4825
Mailing Address - Country:US
Mailing Address - Phone:787-459-2500
Mailing Address - Fax:787-270-1417
Practice Address - Street 1:PARCELAS CARMEN
Practice Address - Street 2:CARR. # 2 KM 29.5
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-270-1417
Practice Address - Fax:787-270-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2679261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental