Provider Demographics
NPI:1437776051
Name:CARRILLO, GLADYS EDITH (DDS)
Entity Type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:EDITH
Last Name:CARRILLO
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 1:4619 SAN DARIO AVE STE 241
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041
Mailing Address - Country:US
Mailing Address - Phone:956-999-8250
Mailing Address - Fax:956-999-8250
Practice Address - Street 1:WASHINGTON 2107
Practice Address - Street 2:
Practice Address - City:NUEVO LAREDO
Practice Address - State:MEXICO
Practice Address - Zip Code:88000
Practice Address - Country:MX
Practice Address - Phone:867-719-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ39788691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice