Healthcare Provider Details

I. General information

NPI: 1861877102
Provider Name (Legal Business Name): NATALIA VALDERRAMA, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 JORDAN BLASS DR STE 102
MELBOURNE FL
32940-1325
US

IV. Provider business mailing address

976 WILDWOOD DR
MELBOURNE FL
32940-1506
US

V. Phone/Fax

Practice location:
  • Phone: 321-544-4127
  • Fax:
Mailing address:
  • Phone: 904-434-7783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN19651
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN19651
License Number StateFL

VIII. Authorized Official

Name: DR. NATALIA VALDERRAMA DOUGHERTY
Title or Position: PRESIDENT/OWNER
Credential: DDS, MS
Phone: 904-434-7783