Provider Demographics
NPI:1609473768
Name:CARRILLO, CARLOS A (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:A
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 W BEAUREGARD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3813
Mailing Address - Country:US
Mailing Address - Phone:325-480-1127
Mailing Address - Fax:
Practice Address - Street 1:2014 W BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3813
Practice Address - Country:US
Practice Address - Phone:325-480-1127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX367351223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty