Provider Demographics
NPI:1265845457
Name:ORTEGA ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:ORTEGA ORTHODONTICS, PLLC
Other - Org Name:ORTEGA ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:VAUGHN
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:904-388-4600
Mailing Address - Street 1:5435 ORTEGA BLVD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-8435
Mailing Address - Country:US
Mailing Address - Phone:904-388-4600
Mailing Address - Fax:904-389-9499
Practice Address - Street 1:5435 ORTEGA BLVD
Practice Address - Street 2:SUITE #2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-8435
Practice Address - Country:US
Practice Address - Phone:904-388-4600
Practice Address - Fax:904-389-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18644261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental