Provider Demographics
NPI:1609527670
Name:DEMETREE, CARLETTA ANNYSE (DDS)
Entity Type:Individual
Prefix:
First Name:CARLETTA
Middle Name:ANNYSE
Last Name:DEMETREE
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 1:1755 OCEAN AVE APT 510
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-3620
Mailing Address - Country:US
Mailing Address - Phone:678-468-0941
Mailing Address - Fax:
Practice Address - Street 1:323 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2842
Practice Address - Country:US
Practice Address - Phone:310-392-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107002122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist