Provider Demographics
NPI:1396205407
Name:CARRILLO GARCIA BANGO, CAMILA (DDS)
Entity Type:Individual
Prefix:
First Name:CAMILA
Middle Name:
Last Name:CARRILLO GARCIA BANGO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NE 25TH ST APT 1103
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-5047
Mailing Address - Country:US
Mailing Address - Phone:786-420-9001
Mailing Address - Fax:
Practice Address - Street 1:250 NE 25TH ST APT 1103
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-5047
Practice Address - Country:US
Practice Address - Phone:786-420-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist