Provider Demographics
NPI:1780831016
Name:CASTRO-PERDOMO, CARLOS ANDRES (DDS)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANDRES
Last Name:CASTRO-PERDOMO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 ATKINSON RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5003
Mailing Address - Country:US
Mailing Address - Phone:917-907-2185
Mailing Address - Fax:
Practice Address - Street 1:1942 ATKINSON RD
Practice Address - Street 2:SUITE 500
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5003
Practice Address - Country:US
Practice Address - Phone:917-907-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0137641223G0001X, 1223P0700X
NY0560551223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0700XDental ProvidersDentistProsthodontics