Provider Demographics
NPI:1174979991
Name:CARRILLO, RICARDO CARLO (DDS)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:CARLO
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RICARDO
Other - Middle Name:CARLO
Other - Last Name:CARRILLO GIRALDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1993 DANIELS RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4598
Mailing Address - Country:US
Mailing Address - Phone:703-341-7769
Mailing Address - Fax:407-395-8470
Practice Address - Street 1:1993 DANIELS RD STE 120
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4598
Practice Address - Country:US
Practice Address - Phone:407-395-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233391223G0001X
FL1507390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1174979991Medicaid