MEDICARE: ORLY DENTAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	18773	TX

General Provider Information

NPI Number	:	1275829368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORLY DENTAL PC

Provider Business Mailing Address
First Line	:	4935 W COMMERCE ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78237-1508
Country	:	US
Telephone Number	:	210-438-0700
Fax Number	:	210-438-0701

Provider Business Practice Location Address
First Line	:	4935 W COMMERCE ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78237-1508
Country	:	US
Telephone Number	:	210-438-0700
Fax Number	:	210-438-0701

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. ORLANDO ORTIZ JR.
Credential	:	DDS
Telephone Number	:	281-857-2961

Provider Enumeration Date	:	06/27/2011
Last Update Date	:	06/27/2011

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