Healthcare Provider Details

I. General information

NPI: 1780150938
Provider Name (Legal Business Name): JOSE LUIS BELTRAN DMD MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11424 N 56TH ST
TEMPLE TERRACE FL
33617-2237
US

IV. Provider business mailing address

11424 N 56TH ST
TEMPLE TERRACE FL
33617-2237
US

V. Phone/Fax

Practice location:
  • Phone: 813-373-4573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSE BELTRAN
Title or Position: OWNER
Credential:
Phone: 818-373-4573