Provider Demographics
NPI:1700299104
Name:GRUPO DENTAL PEDIATRICO SAN JUAN CSP
Entity type:Organization
Organization Name:GRUPO DENTAL PEDIATRICO SAN JUAN CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:YILDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:I
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-753-1475
Mailing Address - Street 1:576 AVE CESAR GONZALEZ SUITE 307
Mailing Address - Street 2:GRUPO DENTAL PEDIATRICO DORAL BANK CENTER
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-0000
Mailing Address - Country:US
Mailing Address - Phone:787-753-1405
Mailing Address - Fax:787-753-1475
Practice Address - Street 1:576 AVE CESAR GONZALEZ SUITE 307
Practice Address - Street 2:GRUPO DENTAL PEDIATRICO DORAL BANK CENTER
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-0000
Practice Address - Country:US
Practice Address - Phone:787-753-1405
Practice Address - Fax:787-753-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2767122300000X
PR24721223P0221X
PR28411223P0221X
PR6181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty