Provider Demographics
NPI:1326418179
Name:RUIZ MATURANA, LETICIA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:RUIZ MATURANA
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 1:21380SW 244 ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33031
Mailing Address - Country:US
Mailing Address - Phone:315-440-7413
Mailing Address - Fax:
Practice Address - Street 1:21380 SW 244TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33031-3628
Practice Address - Country:US
Practice Address - Phone:315-440-7413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20150624005126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant