Provider Demographics
NPI:1700809951
Name:ORTEGA, JESUS ROBERT (DDS)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ROBERT
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:J
Other - Middle Name:ROBERT
Other - Last Name:ORTEGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:612 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-468-3838
Mailing Address - Fax:707-462-5089
Practice Address - Street 1:1377 SOUTH DORA STREET
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482
Practice Address - Country:US
Practice Address - Phone:707-462-3875
Practice Address - Fax:707-462-5089
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA265001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice