Provider Demographics
NPI:1629754627
Name:FUENMAYOR ORTEGA, VERONICA LUCIA
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:LUCIA
Last Name:FUENMAYOR ORTEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 W KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8949
Mailing Address - Country:US
Mailing Address - Phone:918-307-0909
Mailing Address - Fax:
Practice Address - Street 1:3451 W KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8949
Practice Address - Country:US
Practice Address - Phone:918-307-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK79131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice