Provider Demographics
NPI:1487011128
Name:CAVITY REPAIR LLC
Entity type:Organization
Organization Name:CAVITY REPAIR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAFONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-515-7036
Mailing Address - Street 1:122 PALMAS PLANTATION
Mailing Address - Street 2:TEE STREET
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-6022
Mailing Address - Country:US
Mailing Address - Phone:787-515-7136
Mailing Address - Fax:787-885-0560
Practice Address - Street 1:PALMAS PLANTATION
Practice Address - Street 2:122
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-6022
Practice Address - Country:US
Practice Address - Phone:787-515-7036
Practice Address - Fax:787-885-0560
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAVITY REPAIR LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2080261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental