Provider Demographics
NPI:1104139914
Name:TRUJILLO DENTAL CLINIC PSC
Entity type:Organization
Organization Name:TRUJILLO DENTAL CLINIC PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ RAMON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-755-3045
Mailing Address - Street 1:PO BOX 51597
Mailing Address - Street 2:PO BOX 51597
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-1597
Mailing Address - Country:US
Mailing Address - Phone:787-755-3045
Mailing Address - Fax:787-292-0277
Practice Address - Street 1:206 CALLE DR FERNANDEZ
Practice Address - Street 2:206 DR FERNANDEZ
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-5939
Practice Address - Country:US
Practice Address - Phone:787-755-3045
Practice Address - Fax:787-292-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR04501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1083642029OtherNPI
PR1114006079OtherNPI
PR1164410619OtherNPI
PR1184793374OtherNPI