Provider Demographics
NPI:1568723328
Name:ORTIZ, EVELYN C
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:C
Last Name:ORTIZ
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 1:4808 NEW BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6628
Mailing Address - Country:US
Mailing Address - Phone:407-897-1120
Mailing Address - Fax:407-898-0651
Practice Address - Street 1:4808 NEW BROAD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6628
Practice Address - Country:US
Practice Address - Phone:407-897-1120
Practice Address - Fax:407-898-0651
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19718122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist