Provider Demographics
NPI:1881984854
Name:CLINICA DENTAL JIREH
Entity type:Organization
Organization Name:CLINICA DENTAL JIREH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-786-4133
Mailing Address - Street 1:PO BOX 1435
Mailing Address - Street 2:
Mailing Address - City:SABANA SECA
Mailing Address - State:PR
Mailing Address - Zip Code:00952
Mailing Address - Country:UM
Mailing Address - Phone:787-786-4133
Mailing Address - Fax:
Practice Address - Street 1:R14 COLINA LA MARQUESA
Practice Address - Street 2:URB LAS COLINAS
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949-4930
Practice Address - Country:US
Practice Address - Phone:787-786-4133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR20291223G0001X
PR21551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1902947294OtherDRA LIVIA M CRUZ FELIX
PR1821038191OtherDR ANGEL I HERNANDEZ PEREZ