Provider Demographics
NPI:1912230913
Name:VALDES, JORGE ELLER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ELLER
Last Name:VALDES
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 1:10590 ENDURING FREEDOM DRIVE
Mailing Address - Street 2:US ARMY DENTAL HQS FT DRUM
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5005
Mailing Address - Country:US
Mailing Address - Phone:315-772-6234
Mailing Address - Fax:315-772-2393
Practice Address - Street 1:10590 ENDURING FREEDOM DRIVE
Practice Address - Street 2:US ARMY DENTAL HQS FT DRUM
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5005
Practice Address - Country:US
Practice Address - Phone:315-772-6234
Practice Address - Fax:315-772-2393
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02423000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist