Provider Demographics
NPI:1861877102
Name:NATALIA VALDERRAMA, DDS, PA
Entity type:Organization
Organization Name:NATALIA VALDERRAMA, DDS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDERRAMA DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:904-434-7783
Mailing Address - Street 1:976 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1506
Mailing Address - Country:US
Mailing Address - Phone:904-434-7783
Mailing Address - Fax:
Practice Address - Street 1:903 JORDAN BLASS DR STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1325
Practice Address - Country:US
Practice Address - Phone:321-544-4127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19651261QD0000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty