Healthcare Provider Details

I. General information

NPI: 1912230913
Provider Name (Legal Business Name): JORGE ELLER VALDES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 ENDURING FREEDOM DRIVE US ARMY DENTAL HQS FT DRUM
FORT DRUM NY
13602-5005
US

IV. Provider business mailing address

10590 ENDURING FREEDOM DRIVE US ARMY DENTAL HQS FT DRUM
FORT DRUM NY
13602-5005
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-6234
  • Fax: 315-772-2393
Mailing address:
  • Phone: 315-772-6234
  • Fax: 315-772-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDI02423000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: