Provider Demographics
NPI:1871740308
Name:ABC PEDIATRIC DENTAL CLINIC, PSC
Entity type:Organization
Organization Name:ABC PEDIATRIC DENTAL CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-727-3838
Mailing Address - Street 1:253 CALLE SAN JORGE
Mailing Address - Street 2:SUITE I-A SAN JORGE II BUILDING
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00912-3307
Mailing Address - Country:US
Mailing Address - Phone:787-727-3838
Mailing Address - Fax:787-727-3821
Practice Address - Street 1:253 CALLE SAN JORGE
Practice Address - Street 2:SUITE I-A SAN JORGE II BUILDING
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00912-3307
Practice Address - Country:US
Practice Address - Phone:787-727-3838
Practice Address - Fax:787-727-3821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR24241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty