Provider Demographics
NPI:1770700437
Name:EDWARD S MORTELLARO JR DMD PA
Entity type:Organization
Organization Name:EDWARD S MORTELLARO JR DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:MORTELLARO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-685-7733
Mailing Address - Street 1:710 OAKFIELD DRIVE
Mailing Address - Street 2:SUITE 126
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4907
Mailing Address - Country:US
Mailing Address - Phone:813-685-7733
Mailing Address - Fax:813-681-9726
Practice Address - Street 1:710 OAKFIELD DRIVE
Practice Address - Street 2:SUITE 126
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4907
Practice Address - Country:US
Practice Address - Phone:813-685-7733
Practice Address - Fax:813-681-9726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN80611223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty