MEDICARE: EVELYN C ORTIZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN19718	FL

General Provider Information

NPI Number	:	1568723328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVELYN C ORTIZ

Provider Business Mailing Address
First Line	:	4808 NEW BROAD ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32814-6628
Country	:	US
Telephone Number	:	407-897-1120
Fax Number	:	407-898-0651

Provider Business Practice Location Address
First Line	:	4808 NEW BROAD ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32814-6628
Country	:	US
Telephone Number	:	407-897-1120
Fax Number	:	407-898-0651

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2012
Last Update Date	:	06/07/2012

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Directions to “ EVELYN C ORTIZ ” Practice Location

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