Provider Demographics
NPI:1194193508
Name:JORGE, IVETTE (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:IVETTE
Middle Name:
Last Name:JORGE
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32745
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5420
Mailing Address - Country:US
Mailing Address - Phone:786-201-6201
Mailing Address - Fax:
Practice Address - Street 1:3030 N 3RD ST STE 900
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3048
Practice Address - Country:US
Practice Address - Phone:602-274-8181
Practice Address - Fax:602-274-8181
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ92911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice