Provider Demographics
NPI:1508200635
Name:CARBALLO, MAURO
Entity Type:Individual
Prefix:
First Name:MAURO
Middle Name:
Last Name:CARBALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 SW 148TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-3920
Mailing Address - Country:US
Mailing Address - Phone:305-215-8236
Mailing Address - Fax:
Practice Address - Street 1:13768 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-3030
Practice Address - Country:US
Practice Address - Phone:786-501-2163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist