Provider Demographics
NPI:1336544857
Name:SAN JUAN ENDODONTICS PSC
Entity Type:Organization
Organization Name:SAN JUAN ENDODONTICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:AGUSTIN
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-765-7248
Mailing Address - Street 1:1738 AMARILLO ST.
Mailing Address - Street 2:BOX 16
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-765-7248
Mailing Address - Fax:
Practice Address - Street 1:1738 CALLE AMARILLO
Practice Address - Street 2:SUITE 207-B (BOX 16)
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-3072
Practice Address - Country:US
Practice Address - Phone:787-765-7248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2008261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental