Provider Demographics
NPI:1760809354
Name:CHAVEZ-MAYORGA, CARLA L (DDS)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:L
Last Name:CHAVEZ-MAYORGA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:LUCIA
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1222 JEFFERSON PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3410
Practice Address - Country:US
Practice Address - Phone:434-924-1774
Practice Address - Fax:434-243-6378
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411881122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program