Provider Demographics
NPI:1679666465
Name:OFICINA DENTAL FAMILIAR CSP
Entity type:Organization
Organization Name:OFICINA DENTAL FAMILIAR CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRMA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-878-2805
Mailing Address - Street 1:PO BOX 1235
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613
Mailing Address - Country:US
Mailing Address - Phone:787-878-2805
Mailing Address - Fax:787-878-3887
Practice Address - Street 1:OFICINA DENTAL FAMILIAR 1254 SANTANA
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-878-2805
Practice Address - Fax:787-878-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2487122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR206473OtherPREFERRED HEALTH
PR6120160OtherHUMANA
PR043021OtherBCBS
PR42470OtherSSS
PR70584OtherPREFERRED MEDICAL CHOICE