Provider Demographics
NPI:1992894190
Name:BORTELL, ELIZABETH BAKER (DDS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BAKER
Last Name:BORTELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 BROOK RD
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-1215
Mailing Address - Country:US
Mailing Address - Phone:804-321-7474
Mailing Address - Fax:804-228-5970
Practice Address - Street 1:2924 BROOK RD
Practice Address - Street 2:CREDENTIALING DEPT
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-1215
Practice Address - Country:US
Practice Address - Phone:804-321-7474
Practice Address - Fax:804-228-5970
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014103081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401410308OtherPROFESSIONAL LICENSE