Provider Demographics
NPI:1912174699
Name:CENTRO PERIODONTAL DEL ESTE,CSP
Entity Type:Organization
Organization Name:CENTRO PERIODONTAL DEL ESTE,CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-852-4475
Mailing Address - Street 1:53 CALLE FONT MARTELO E
Mailing Address - Street 2:OFICINA 104
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791
Mailing Address - Country:US
Mailing Address - Phone:787-852-4475
Mailing Address - Fax:787-285-0632
Practice Address - Street 1:HUMACAO MEDICAL PLAZA AVE. FONT MARTELO
Practice Address - Street 2:OFFIC 104
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-852-4475
Practice Address - Fax:787-285-0632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2009261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental