Provider Demographics
NPI:1306256276
Name:ORTIZ-DIAZ, CRISTINA (DMD, MSD)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:ORTIZ-DIAZ
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 CALLE NOGAL
Mailing Address - Street 2:MONTECASINO
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-3725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 CARR 2 STE 301
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692-6092
Practice Address - Country:US
Practice Address - Phone:787-883-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPRV-FP-108-201223S0112X
NY058198-11223S0112X
PR32951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR038821200Medicaid