=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083874424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARICELLE R. ORTIZ-LUIS, DDS, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2008
-----------------------------------------------------
Last Update Date | 06/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2515 PIO PICO DR SUITE B
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-434-3119
-----------------------------------------------------
Fax | 760-434-3438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2515 PIO PICO DR SUITE B
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-434-3119
-----------------------------------------------------
Fax | 760-434-3438
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARICELLE R ORTIZ-LUIS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 760-434-3119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 47653
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------