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General NPI Number Information
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NPI Number | 1003382490
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Entity Type | Individual
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Provider Name | MIREYA E IMITOLA ORTA
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Gender | Female
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Dates
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Enumeration Date | 10/23/2018
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Last Update Date | 10/23/2018
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Provider Practice Location Address
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Address Line | 2305 CEDAR SPRINGS RD
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City | DALLAS
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State | TX
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Zip | 75201-1854
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Country | US
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Telephone | 214-969-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 2820 GOLDEN MEADOW AVE
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City | MESQUITE
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State | TX
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Zip | 75181-2147
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Country | US
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Telephone | 972-310-1172
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 34534
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License Number State | TX
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