Provider Demographics
NPI:1467501890
Name:ORTEGA, MIREYA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIREYA
Middle Name:
Last Name:ORTEGA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 SKI RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-541-7040
Mailing Address - Fax:530-541-3429
Practice Address - Street 1:1060 SKI RUN BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-541-7040
Practice Address - Fax:530-541-3429
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0355301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice