Provider Demographics
NPI:1962726984
Name:OFICINA DENTAL LOS DOMINICOS, PSC
Entity type:Organization
Organization Name:OFICINA DENTAL LOS DOMINICOS, PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:MRS
Authorized Official - Phone:787-784-0520
Mailing Address - Street 1:AVE BOULEVARD, LOS DOMINICOS SHOPPING CENTER
Mailing Address - Street 2:LOCAL 21-B
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949-0000
Mailing Address - Country:US
Mailing Address - Phone:787-787-0520
Mailing Address - Fax:
Practice Address - Street 1:AVE BOULEVARD, LOS DOMINICOS SHOPPING CENTER
Practice Address - Street 2:LOCAL 21 B , LEVITTOWN
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949-0000
Practice Address - Country:US
Practice Address - Phone:787-784-0520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2242305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization