Provider Demographics
NPI:1972282317
Name:HENAO ORTEGA, CARLOS MAURICIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:MAURICIO
Last Name:HENAO ORTEGA
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 1:24515 ROSETTE LN
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-3036
Mailing Address - Country:US
Mailing Address - Phone:314-315-6999
Mailing Address - Fax:
Practice Address - Street 1:25044 PEACHLAND AVENUE SUITE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-5746
Practice Address - Country:US
Practice Address - Phone:661-287-4352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109335122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist