Provider Demographics
NPI:1699949925
Name:OPTIMUM DENTAL CLINIC
Entity type:Organization
Organization Name:OPTIMUM DENTAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DONATO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:1787-880-2500
Mailing Address - Street 1:PO BOX 140082
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-0082
Mailing Address - Country:US
Mailing Address - Phone:178-788-0250
Mailing Address - Fax:178-781-6250
Practice Address - Street 1:CARRETERA #653 KM 1.3
Practice Address - Street 2:BO. CORCOVADA
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-0000
Practice Address - Country:US
Practice Address - Phone:178-788-0250
Practice Address - Fax:178-781-6250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental