Provider Demographics
NPI:1083808661
Name:ORTIZ, JAN N (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:N
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E CAMPBELL RD STE 230
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-2042
Mailing Address - Country:US
Mailing Address - Phone:972-479-1200
Mailing Address - Fax:972-479-1203
Practice Address - Street 1:700 E CAMPBELL RD STE 230
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2042
Practice Address - Country:US
Practice Address - Phone:972-479-1200
Practice Address - Fax:972-479-1203
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261641223X0400X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287540301Medicaid