Provider Demographics
NPI:1578866430
Name:CARMONA, ENRIQUETA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:ENRIQUETA
Middle Name:
Last Name:CARMONA
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 1:4096 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6147
Mailing Address - Country:US
Mailing Address - Phone:323-569-3333
Mailing Address - Fax:323-569-3334
Practice Address - Street 1:4096 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6147
Practice Address - Country:US
Practice Address - Phone:323-569-3333
Practice Address - Fax:323-569-3334
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CA60024122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies