Provider Demographics
NPI:1215976758
Name:ORTINAU, MARK M (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:ORTINAU
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 1:12 HUTCHINSON RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-5702
Mailing Address - Country:US
Mailing Address - Phone:636-391-0122
Mailing Address - Fax:636-391-0185
Practice Address - Street 1:12 HUTCHINSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-5702
Practice Address - Country:US
Practice Address - Phone:636-391-0122
Practice Address - Fax:636-391-0185
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist