Basic Information
| Provider Information | |||||||||
| NPI: | 1366876096 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVANCA DENTAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38-B CALLE BETANCES | ||||||||
| Address2: | |||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006934453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878553996 | ||||||||
| FaxNumber: | 7878553996 | ||||||||
| Practice Location | |||||||||
| Address1: | 38-B CALLE BETANCES | ||||||||
| Address2: | |||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006934453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878553996 | ||||||||
| FaxNumber: | 7878553996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2013 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | OTERO | ||||||||
| AuthorizedOfficialFirstName: | TIARA | ||||||||
| AuthorizedOfficialMiddleName: | NAHIR | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7878553996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2777 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.