Provider Demographics
NPI:1063666907
Name:ORTIZ-RIVERA, MELBA L
Entity Type:Individual
Prefix:
First Name:MELBA
Middle Name:L
Last Name:ORTIZ-RIVERA
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 1:1255 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-1128
Mailing Address - Country:US
Mailing Address - Phone:850-342-0170
Mailing Address - Fax:850-342-0257
Practice Address - Street 1:1205 E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3831
Practice Address - Country:US
Practice Address - Phone:956-542-1956
Practice Address - Fax:956-542-3672
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25271122300000X, 1223G0001X
FLDN185101223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210080206Medicaid