Provider Demographics
NPI:1619047586
Name:MORENO, CARLO (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLO
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 UNIVERSITY AVE A201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-543-0112
Mailing Address - Fax:619-543-0094
Practice Address - Street 1:1060 UNIVERSITY AVE # A201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3310
Practice Address - Country:US
Practice Address - Phone:619-543-0112
Practice Address - Fax:619-543-0094
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice