Provider Demographics
NPI:1194068544
Name:MORTELLARO, EDWARD SALVATORE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:SALVATORE
Last Name:MORTELLARO
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 OAKFIELD DR
Mailing Address - Street 2:SUITE 126
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4938
Mailing Address - Country:US
Mailing Address - Phone:813-685-7733
Mailing Address - Fax:813-681-9723
Practice Address - Street 1:710 OAKFIELD DR
Practice Address - Street 2:SUITE 126
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4938
Practice Address - Country:US
Practice Address - Phone:813-685-7733
Practice Address - Fax:813-681-9723
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 80611223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics