Provider Demographics
NPI:1164625075
Name:CARRACEDO, ERWIN TAMAYO (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERWIN
Middle Name:TAMAYO
Last Name:CARRACEDO
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 1:3540 CALLAN BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080
Mailing Address - Country:US
Mailing Address - Phone:650-742-9092
Mailing Address - Fax:650-742-9093
Practice Address - Street 1:1331 GUERNEVILLE RD
Practice Address - Street 2:SUITE G
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-4162
Practice Address - Country:US
Practice Address - Phone:650-742-9092
Practice Address - Fax:650-742-9093
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice