Provider Demographics
NPI:1619292117
Name:ERWIN T CARRACEDO DMD, INC
Entity Type:Organization
Organization Name:ERWIN T CARRACEDO DMD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERWIN
Authorized Official - Middle Name:TAMAYO
Authorized Official - Last Name:CARRACEDO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:650-742-9092
Mailing Address - Street 1:3540 CALLAN BLVD. STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080
Mailing Address - Country:US
Mailing Address - Phone:650-742-9092
Mailing Address - Fax:650-742-9093
Practice Address - Street 1:3540 CALLAN BLVD. STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080
Practice Address - Country:US
Practice Address - Phone:650-742-9092
Practice Address - Fax:650-742-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40417122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty