Provider Demographics
NPI:1639501638
Name:JUSTINIANO AYALA, JULISSA (DDS)
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:JUSTINIANO AYALA
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 1:10231 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4353
Mailing Address - Country:US
Mailing Address - Phone:407-985-2885
Mailing Address - Fax:407-985-2887
Practice Address - Street 1:10231 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4353
Practice Address - Country:US
Practice Address - Phone:407-985-2885
Practice Address - Fax:407-985-2887
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist