Provider Demographics
NPI:1376847046
Name:ORTHODONTICS OF
Entity Type:Organization
Organization Name:ORTHODONTICS OF
Other - Org Name:CENTRAL FLORIDA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJESUS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-826-0111
Mailing Address - Street 1:14055 TOWN LOOP BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6105
Mailing Address - Country:US
Mailing Address - Phone:407-826-0111
Mailing Address - Fax:407-851-4208
Practice Address - Street 1:14055 TOWN LOOP BLVD
Practice Address - Street 2:STE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6105
Practice Address - Country:US
Practice Address - Phone:407-826-0111
Practice Address - Fax:407-851-4208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN133131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074375500Medicaid