Provider Demographics
NPI:1255707568
Name:CR DIAZ BONILLA DENTISTA PEDIATRICA PSC
Entity type:Organization
Organization Name:CR DIAZ BONILLA DENTISTA PEDIATRICA PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:CAREM
Authorized Official - Middle Name:ROSA
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-447-0892
Mailing Address - Street 1:E28 CALLE 14
Mailing Address - Street 2:URB QUINTAS DE CUPEY
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-735-0575
Mailing Address - Fax:787-735-2390
Practice Address - Street 1:51 AVE SAN JOSE
Practice Address - Street 2:SUITE 203
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-735-0575
Practice Address - Fax:787-735-2390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR23341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty