Healthcare Provider Details

I. General information

NPI: 1225731441
Provider Name (Legal Business Name): GUSTAVO ADOLFO ORTEGON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 07/02/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N ASH ST
PEARSALL TX
78061-3201
US

IV. Provider business mailing address

5039 HAMILTON WOLFE RD APT 3214
SAN ANTONIO TX
78229-0019
US

V. Phone/Fax

Practice location:
  • Phone: 830-334-3333
  • Fax:
Mailing address:
  • Phone: 954-778-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41605
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: