Provider Demographics
NPI:1295211977
Name:ZEVALLOS CARRILLO, DANIEL ANTONIO (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ANTONIO
Last Name:ZEVALLOS CARRILLO
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 1:3915 2ND AVE NE APT 105
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 RAMSAY WAY STE 109
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4536
Practice Address - Country:US
Practice Address - Phone:253-638-6046
Practice Address - Fax:253-520-4009
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA608617081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice