Provider Demographics
NPI:1154327005
Name:IBANEZ, CARLOS R (DDS)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:IBANEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 ROLKIN COURT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911
Mailing Address - Country:US
Mailing Address - Phone:434-295-0911
Mailing Address - Fax:434-295-4139
Practice Address - Street 1:1415 ROLKIN COURT
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911
Practice Address - Country:US
Practice Address - Phone:434-295-0911
Practice Address - Fax:434-295-4139
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA04014122241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery