Provider Demographics
NPI:1225457658
Name:BETANCUR, LUISA FERNANDA
Entity Type:Individual
Prefix:
First Name:LUISA
Middle Name:FERNANDA
Last Name:BETANCUR
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 1:6365 SW 134TH LOOP
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34473-8195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 SE 17TH ST
Practice Address - Street 2:500
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4191
Practice Address - Country:US
Practice Address - Phone:352-368-9099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2016-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL206641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics