Healthcare Provider Details

I. General information

NPI: 1669521209
Provider Name (Legal Business Name): DR. MARITZA O DE JESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14055 TOWN LOOP BLVD STE 100
ORLANDO FL
32837-6105
US

IV. Provider business mailing address

14055 TOWN LOOP BLVD STE 100
ORLANDO FL
32837-6105
US

V. Phone/Fax

Practice location:
  • Phone: 407-826-0111
  • Fax: 407-851-4208
Mailing address:
  • Phone: 407-826-0111
  • Fax: 407-851-4208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN13313
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: