Provider Demographics
NPI:1508120999
Name:CARBONE, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:CARBONE
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 1:350 N MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-2439
Mailing Address - Country:US
Mailing Address - Phone:626-434-0484
Mailing Address - Fax:
Practice Address - Street 1:350 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2439
Practice Address - Country:US
Practice Address - Phone:626-434-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25950124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25950OtherREGISTERED DENTAL HYGIENIST