Provider Demographics
NPI:1760861769
Name:ORTIZ, MARIELY NICOLE (DMD)
Entity Type:Individual
Prefix:
First Name:MARIELY
Middle Name:NICOLE
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EXT VILLA MILAGROS
Mailing Address - Street 2:46 RENE ALFONSO
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698
Mailing Address - Country:US
Mailing Address - Phone:787-202-8826
Mailing Address - Fax:
Practice Address - Street 1:CALLE GUILLERMO RIESKOHL
Practice Address - Street 2:
Practice Address - City:PATILLAS
Practice Address - State:PR
Practice Address - Zip Code:00723-0697
Practice Address - Country:US
Practice Address - Phone:787-839-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR32521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice