Provider Demographics
NPI:1174723100
Name:ORTOLA, JOSEPH A (DDS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:ORTOLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 S. FORTUNA BLVD.
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3002
Mailing Address - Country:US
Mailing Address - Phone:707-725-4419
Mailing Address - Fax:707-725-3233
Practice Address - Street 1:569 S. FORTUNA BLVD.
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3002
Practice Address - Country:US
Practice Address - Phone:707-725-4419
Practice Address - Fax:707-725-3233
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist