Provider Demographics
NPI:1750499547
Name:DECASTRO, GUARIONEX (DMD, PA)
Entity Type:Individual
Prefix:
First Name:GUARIONEX
Middle Name:
Last Name:DECASTRO
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5917 W 12TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1608
Mailing Address - Country:US
Mailing Address - Phone:501-663-8307
Mailing Address - Fax:501-663-8308
Practice Address - Street 1:5917 W 12TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1608
Practice Address - Country:US
Practice Address - Phone:501-663-8307
Practice Address - Fax:501-663-8308
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3449122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR3449OtherDELTA DENTAL
AR5X734OtherBLUE CROSS BLUE SHIELD