Provider Demographics
NPI:1518468099
Name:CARRASCO ROMAN, GLADYS G
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:G
Last Name:CARRASCO ROMAN
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 1:2 INWOOD DR APT 1005
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-5279
Mailing Address - Country:US
Mailing Address - Phone:617-270-1405
Mailing Address - Fax:
Practice Address - Street 1:180 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150
Practice Address - Country:US
Practice Address - Phone:617-889-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF11267122300000X
VT016.01339931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist