Provider Demographics
NPI:1205404456
Name:HUERGO, CARLOS J (DMD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:J
Last Name:HUERGO
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 1:9898 ROOSEVELT BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-1730
Mailing Address - Country:US
Mailing Address - Phone:267-691-5048
Mailing Address - Fax:
Practice Address - Street 1:9898 ROOSEVELT BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1730
Practice Address - Country:US
Practice Address - Phone:267-691-5048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043188122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist