Provider Demographics
NPI:1164170916
Name:ULRICH, IOANNA BORISSOVA (DMD)
Entity Type:Individual
Prefix:DR
First Name:IOANNA
Middle Name:BORISSOVA
Last Name:ULRICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 SYLVIA LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2005
Mailing Address - Country:US
Mailing Address - Phone:813-955-2837
Mailing Address - Fax:
Practice Address - Street 1:16821 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6714
Practice Address - Country:US
Practice Address - Phone:616-635-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN243151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics