Provider Demographics
NPI:1639552102
Name:EL HAITAMI, CARLY (DMD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:EL HAITAMI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10718 BELLE MAISONS DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5142
Mailing Address - Country:US
Mailing Address - Phone:217-491-2016
Mailing Address - Fax:
Practice Address - Street 1:2511 S ORANGE AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4545
Practice Address - Country:US
Practice Address - Phone:217-491-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist