Provider Demographics
NPI:1124869342
Name:CLEVELAND DENTAL PLLC
Entity type:Organization
Organization Name:CLEVELAND DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:281-520-2150
Mailing Address - Street 1:7727 ADAGIO AVE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-2536
Mailing Address - Country:US
Mailing Address - Phone:281-520-2150
Mailing Address - Fax:
Practice Address - Street 1:1214 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4754
Practice Address - Country:US
Practice Address - Phone:281-520-2150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1891308433Medicaid