Provider Demographics
NPI:1750712162
Name:THIRD MOLAR INC
Entity type:Organization
Organization Name:THIRD MOLAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:RAMIREZ DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-786-8540
Mailing Address - Street 1:429 CALLE REY LUIS
Mailing Address - Street 2:LA VILLA DE TORRIMAR
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-3170
Mailing Address - Country:US
Mailing Address - Phone:787-786-8540
Mailing Address - Fax:787-995-0431
Practice Address - Street 1:I47 CALLE I
Practice Address - Street 2:EXTENSION HERMANAS DAVILA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959-5266
Practice Address - Country:US
Practice Address - Phone:787-786-8540
Practice Address - Fax:787-995-0431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1467450809Medicaid