Provider Demographics
NPI:1003382490
Name:IMITOLA ORTA, MIREYA E
Entity Type:Individual
Prefix:
First Name:MIREYA
Middle Name:E
Last Name:IMITOLA ORTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 GOLDEN MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-2147
Mailing Address - Country:US
Mailing Address - Phone:972-310-1172
Mailing Address - Fax:
Practice Address - Street 1:2305 CEDAR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-1854
Practice Address - Country:US
Practice Address - Phone:214-969-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345341223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics