Provider Demographics
NPI:1669521209
Name:DE JESUS, MARITZA O
Entity type:Individual
Prefix:DR
First Name:MARITZA
Middle Name:O
Last Name:DE JESUS
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 1:14055 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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN133131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics