Provider Demographics
NPI:1619157740
Name:VASQUEZ, CARLA SUE (RDH)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:SUE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX Q
Mailing Address - Street 2:1025 WEST MAIN STREET
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-0397
Mailing Address - Country:US
Mailing Address - Phone:573-431-1947
Mailing Address - Fax:573-431-7326
Practice Address - Street 1:1025 W MAIN ST
Practice Address - Street 2:PO BOX Q
Practice Address - City:PARK HILLS
Practice Address - State:MO
Practice Address - Zip Code:63601-2079
Practice Address - Country:US
Practice Address - Phone:573-431-1947
Practice Address - Fax:573-431-7326
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002643124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist