Provider Demographics
NPI:1235466269
Name:CARBALLO, RODOLFO (DDS)
Entity Type:Individual
Prefix:DR
First Name:RODOLFO
Middle Name:
Last Name:CARBALLO
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 1:18503 PINES BLVD
Mailing Address - Street 2:#208
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1404
Mailing Address - Country:US
Mailing Address - Phone:954-499-0033
Mailing Address - Fax:
Practice Address - Street 1:18503 PINES BLVD
Practice Address - Street 2:#208
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1404
Practice Address - Country:US
Practice Address - Phone:954-499-0033
Practice Address - Fax:954-499-0355
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16140122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist