Provider Demographics
NPI:1740359702
Name:ORTIZ, PHILLIP JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JOHN
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40613 VIA DIAMANTE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-8504
Mailing Address - Country:US
Mailing Address - Phone:951-461-9024
Mailing Address - Fax:951-461-9025
Practice Address - Street 1:40613 VIA DIAMANTE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8504
Practice Address - Country:US
Practice Address - Phone:951-461-9024
Practice Address - Fax:951-461-9025
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD30441-01Medicaid
CAG93640-01Medicaid