MEDICARE: LISA MARIE GORTARI DDS

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	59423	CA
2	122300000X	Dentist	27675	TX
3	1223D0004X	Dental Anesthesiology	27675	TX
4	1223D0004X	Dental Anesthesiology	59423	CA
5	122300000X	Dentist	D008600	AZ
6	1223D0004X	Dental Anesthesiology	D008600	AZ

General Provider Information

NPI Number	:	1730497249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE GORTARI DDS

Provider Business Mailing Address
First Line	:	3301 N K CTR
Second Line	:	D206
City	:	MCALLEN
State	:	TX
Zip	:	78501-1528
Country	:	US
Telephone Number	:	909-229-3134
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 E DOVE AVE
Second Line	:	STE C
City	:	MCALLEN
State	:	TX
Zip	:	78504-2262
Country	:	US
Telephone Number	:	909-229-3134
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2010
Last Update Date	:	01/20/2016

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