Provider Demographics
NPI:1902653348
Name:OSORIO MORATAYA, ESTUARDO JOSE
Entity type:Individual
Prefix:
First Name:ESTUARDO
Middle Name:JOSE
Last Name:OSORIO MORATAYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32203 CAROUSEL LN APT 203
Mailing Address - Street 2:
Mailing Address - City:LUNENBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01462-2444
Mailing Address - Country:US
Mailing Address - Phone:346-323-0915
Mailing Address - Fax:
Practice Address - Street 1:326 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1914
Practice Address - Country:US
Practice Address - Phone:978-878-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL100127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist