Provider Demographics
NPI:1851040067
Name:CARRILLO, MARIANNA RUBY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIANNA
Middle Name:RUBY
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N 24TH ST APT 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1257
Mailing Address - Country:US
Mailing Address - Phone:714-552-7759
Mailing Address - Fax:
Practice Address - Street 1:2470 S STEMMONS FWY
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8755
Practice Address - Country:US
Practice Address - Phone:903-603-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX384331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program