Provider Demographics
NPI:1720751548
Name:ADVANCED ENDODONTIC CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED ENDODONTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:DR
Authorized Official - First Name:SEBASTIAN
Authorized Official - Middle Name:ANDRES
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-641-1340
Mailing Address - Street 1:PLAZA TROPICAL #11
Mailing Address - Street 2:CARR 167 KM. 22.2
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959-9998
Mailing Address - Country:US
Mailing Address - Phone:787-641-1340
Mailing Address - Fax:787-641-0804
Practice Address - Street 1:PLAZA TROPICAL #11
Practice Address - Street 2:CARR 167 KM. 22.2
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-641-1340
Practice Address - Fax:787-641-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-28
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR039141800Medicaid