Provider Demographics
NPI:1821663485
Name:AVILA, CARLE STEPHANIE
Entity Type:Individual
Prefix:
First Name:CARLE
Middle Name:STEPHANIE
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17047 E BYGROVE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1208
Mailing Address - Country:US
Mailing Address - Phone:626-991-0342
Mailing Address - Fax:
Practice Address - Street 1:17047 E BYGROVE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1208
Practice Address - Country:US
Practice Address - Phone:626-991-0342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95027Medicaid