Provider Demographics
NPI:1255680641
Name:ONTIVEROS, LETICIA (RDH)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:ONTIVEROS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49302 W MAYER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-5220
Mailing Address - Country:US
Mailing Address - Phone:520-709-9908
Mailing Address - Fax:
Practice Address - Street 1:3030 N 67TH PL
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6082
Practice Address - Country:US
Practice Address - Phone:480-946-0473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7461124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11150712LOOtherNPI