Provider Demographics
NPI:1003871112
Name:CARRILLO, JUAN MANUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:MANUEL
Last Name:CARRILLO
Suffix:
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 1:2008 JOHN ROLFE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238
Mailing Address - Country:US
Mailing Address - Phone:804-754-2020
Mailing Address - Fax:804-754-2008
Practice Address - Street 1:2008 JOHN ROLFE PARKWAY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238
Practice Address - Country:US
Practice Address - Phone:804-754-2020
Practice Address - Fax:804-754-2008
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410612122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA186588OtherANTHEM ID NUMBER