Provider Demographics
NPI:1891214995
Name:AMARILLAS GASTELUM, CLARISA (DDS,MS)
Entity Type:Individual
Prefix:
First Name:CLARISA
Middle Name:
Last Name:AMARILLAS GASTELUM
Suffix:
Gender:F
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 WESTCHESTER HALL
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8705
Mailing Address - Country:US
Mailing Address - Phone:631-632-8631
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK SCHOOL OF DENTAL MEDICINE SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-632-8631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist