Basic Information
| Provider Information | |||||||||
| NPI: | 1194025627 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROGRAMA GRADUADO CIRUGIA ORAL Y MAXILOFACIAL, UPR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ESCUELA DE MEDICINA DENTAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 365067 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009365067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582525 | ||||||||
| FaxNumber: | 7877510858 | ||||||||
| Practice Location | |||||||||
| Address1: | CENTRO MEDICO RIO PIEDRAS, RECINTO DE CIENCIAS MEDICAS | ||||||||
| Address2: | 1ER PISO, A 127 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582525 | ||||||||
| FaxNumber: | 7877510858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2010 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEON | ||||||||
| AuthorizedOfficialFirstName: | ATILANO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7877582525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 840 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.