Healthcare Provider Details

I. General information

NPI: 1902878747
Provider Name (Legal Business Name): AIDA M SOLIVAN ORTIZ BS, DMD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP, BLDG 4554 ATTN: 59 MDW/SGHC
JBSA LACKLAND TX
78236-9908
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP, BLDG 4554 59 MDW/SGHC
JBSA LACKLAND TX
78236-9908
US

V. Phone/Fax

Practice location:
  • Phone: 210-671-9537
  • Fax:
Mailing address:
  • Phone: 210-292-0722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number24867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: