Provider Demographics
NPI:1356517437
Name:ADVANCE DENTAL CLINIC PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ADVANCE DENTAL CLINIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:JAVIER
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-850-1085
Mailing Address - Street 1:563 CALLE ECHEGARAY
Mailing Address - Street 2:LITHEDA HEIGHTS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-4416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 CALLE DOLORES CABRERA ALONSO E
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-4269
Practice Address - Country:US
Practice Address - Phone:787-850-1085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental