Provider Demographics
NPI:1013155563
Name:DEL CARLO, BRIAN PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PAUL
Last Name:DEL CARLO
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 1:2770 FL GA HWY
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-9202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2770 FL GA HWY
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-9202
Practice Address - Country:US
Practice Address - Phone:630-336-8478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHAD120122300000X
IL0190-25025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114924900Medicaid