Provider Demographics
NPI:1447465042
Name:CENTRO MEDICO DENTAL DEL NORESTE
Entity type:Organization
Organization Name:CENTRO MEDICO DENTAL DEL NORESTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MDS
Authorized Official - Phone:787-525-3946
Mailing Address - Street 1:1311 AMERICO MIRANDA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-2118
Mailing Address - Country:US
Mailing Address - Phone:787-792-2850
Mailing Address - Fax:787-749-0406
Practice Address - Street 1:CARR.3
Practice Address - Street 2:KM 19.6
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-792-2850
Practice Address - Fax:787-749-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty