Provider Demographics
NPI:1083874424
Name:MARICELLE R. ORTIZ-LUIS, DDS, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARICELLE R. ORTIZ-LUIS, DDS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARICELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ORTIZ-LUIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-434-3119
Mailing Address - Street 1:2515 PIO PICO DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1560
Mailing Address - Country:US
Mailing Address - Phone:760-434-3119
Mailing Address - Fax:760-434-3438
Practice Address - Street 1:2515 PIO PICO DR
Practice Address - Street 2:SUITE B
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1560
Practice Address - Country:US
Practice Address - Phone:760-434-3119
Practice Address - Fax:760-434-3438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47653261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental