Healthcare Provider Details

I. General information

NPI: 1255680641
Provider Name (Legal Business Name): LETICIA ONTIVEROS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 N 67TH PL
SCOTTSDALE AZ
85251-6082
US

IV. Provider business mailing address

49302 W MAYER BLVD
MARICOPA AZ
85139-5220
US

V. Phone/Fax

Practice location:
  • Phone: 480-946-0473
  • Fax:
Mailing address:
  • Phone: 520-709-9908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7461
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: