Provider Demographics
NPI:1104381359
Name:CASTIBLANCO DENTAL CARE LLC
Entity Type:Organization
Organization Name:CASTIBLANCO DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:CASTIBLANCO
Authorized Official - Last Name:SHOREY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, DMD
Authorized Official - Phone:770-977-0977
Mailing Address - Street 1:3901 ROSWELL RD STE 220
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8816
Mailing Address - Country:US
Mailing Address - Phone:770-977-0977
Mailing Address - Fax:770-977-2910
Practice Address - Street 1:3901 ROSWELL RD STE 220
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8816
Practice Address - Country:US
Practice Address - Phone:770-977-0977
Practice Address - Fax:770-977-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty