Provider Demographics
NPI:1093892150
Name:DE LA TORRE, CARMEN ELENA (DDS)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:ELENA
Last Name:DE LA TORRE
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 1:336 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-1616
Mailing Address - Country:US
Mailing Address - Phone:305-577-4840
Mailing Address - Fax:
Practice Address - Street 1:336 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-1616
Practice Address - Country:US
Practice Address - Phone:305-577-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075327100Medicaid