Healthcare Provider Details

I. General information

NPI: 1376540013
Provider Name (Legal Business Name): RAYMOND ORTIZ CLASS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ORTIZ CLASS RAYMOND DMD

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date: 03/21/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

ROBERTO CLEMENTE AVE 24 8 VILLA CAROLINA
CAROLINA PR
00985-5401
US

IV. Provider business mailing address

AVE ROBERTO CLEMENTE 24 8 VILLA CAROLINA
CAROLINA PR
00985-5401
US

V. Phone/Fax

Practice location:
  • Phone: 787-757-3080
  • Fax: 787-757-1910
Mailing address:
  • Phone: 787-757-3080
  • Fax: 787-757-1910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2523
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: