Provider Demographics
NPI:1558869917
Name:WALLACE CARRILLO-MEDINA DMD PA
Entity Type:Organization
Organization Name:WALLACE CARRILLO-MEDINA DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO-MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:336-629-3112
Mailing Address - Street 1:511 GREENSBORO ST
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-4736
Mailing Address - Country:US
Mailing Address - Phone:336-629-3112
Mailing Address - Fax:
Practice Address - Street 1:511 GREENSBORO ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-4736
Practice Address - Country:US
Practice Address - Phone:732-692-6929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223X2210X
NC9900261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Single Specialty