Provider Demographics
NPI:1821684713
Name:EVERGREEN DENTAL ANESTHESIA PLLC
Entity Type:Organization
Organization Name:EVERGREEN DENTAL ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CARILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-673-8732
Mailing Address - Street 1:357 MCCASLIN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-2932
Mailing Address - Country:US
Mailing Address - Phone:970-699-8954
Mailing Address - Fax:
Practice Address - Street 1:357 MCCASLIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-2932
Practice Address - Country:US
Practice Address - Phone:970-699-8954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty