=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225457658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUISA FERNANDA BETANCUR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2014
-----------------------------------------------------
Last Update Date | 07/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 SE 17TH ST 500
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-368-9099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6365 SW 134TH LOOP
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34473-8195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 20664
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------