Provider Demographics
NPI:1881871234
Name:ORTEGA, JACQUELINE (DMD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ORTEGA
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 1:1298 N DIXIE FWY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6068
Mailing Address - Country:US
Mailing Address - Phone:386-428-2958
Mailing Address - Fax:
Practice Address - Street 1:1298 N DIXIE FWY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6068
Practice Address - Country:US
Practice Address - Phone:386-428-2958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15720122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist