Healthcare Provider Details

I. General information

NPI: 1154542397
Provider Name (Legal Business Name): CHRISTIE JEAN LATULIPPE D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3781 S NOVA RD
PORT ORANGE FL
32129-4291
US

IV. Provider business mailing address

3781 S NOVA RD
PORT ORANGE FL
32129-4291
US

V. Phone/Fax

Practice location:
  • Phone: 386-574-8388
  • Fax: 386-574-0495
Mailing address:
  • Phone: 386-574-8388
  • Fax: 386-574-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14604
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: