Provider Demographics
NPI:1235741083
Name:CARPIO HERNANDEZ, MARYCARMEN
Entity Type:Individual
Prefix:MRS
First Name:MARYCARMEN
Middle Name:
Last Name:CARPIO HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 N COUNTY ROAD 100 E
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-8309
Mailing Address - Country:US
Mailing Address - Phone:317-946-0703
Mailing Address - Fax:
Practice Address - Street 1:3636 E 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-1454
Practice Address - Country:US
Practice Address - Phone:317-743-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013447A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist