Provider Demographics
NPI:1366876096
Name:IVANCA DENTAL LLC
Entity type:Organization
Organization Name:IVANCA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIARA
Authorized Official - Middle Name:NAHIR
Authorized Official - Last Name:OTERO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:787-855-3996
Mailing Address - Street 1:38-B CALLE BETANCES
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-4453
Mailing Address - Country:US
Mailing Address - Phone:787-855-3996
Mailing Address - Fax:787-855-3996
Practice Address - Street 1:38-B CALLE BETANCES
Practice Address - Street 2:
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-4453
Practice Address - Country:US
Practice Address - Phone:787-855-3996
Practice Address - Fax:787-855-3996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR27771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty