Provider Demographics
NPI:1134585334
Name:CARILLON COSMETIC & GENERAL DENTISTRY
Entity type:Organization
Organization Name:CARILLON COSMETIC & GENERAL DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - OPERATING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGARA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-595-0821
Mailing Address - Street 1:13180 LIVINGSTON RD BLDG 100
Mailing Address - Street 2:SUITE # 106
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-3871
Mailing Address - Country:US
Mailing Address - Phone:239-263-0912
Mailing Address - Fax:239-263-0925
Practice Address - Street 1:13180 LIVINGSTON RD BLDG 100
Practice Address - Street 2:SUITE # 106
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-3871
Practice Address - Country:US
Practice Address - Phone:239-263-0912
Practice Address - Fax:239-263-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL160891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty