Provider Demographics
NPI:1669671269
Name:LASER DENTAL CENTERS,CSP
Entity type:Organization
Organization Name:LASER DENTAL CENTERS,CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTITA
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:FASICK
Authorized Official - Last Name:JULIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-725-4776
Mailing Address - Street 1:PMB 352 # 35 JUAN C BORBON STE 67
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-725-4776
Mailing Address - Fax:787-725-4776
Practice Address - Street 1:ASHFORD MEDICAL CENTER SUITE 808 # 29
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-728-4776
Practice Address - Fax:787-725-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty