Provider Demographics
NPI:1154889988
Name:ANICETO, CARLOS MANUEL
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:MANUEL
Last Name:ANICETO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:983 BENNETT RD APT 201
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6092
Mailing Address - Country:US
Mailing Address - Phone:786-662-9648
Mailing Address - Fax:
Practice Address - Street 1:5285 RED BUG LAKE RD STE 105
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-4973
Practice Address - Country:US
Practice Address - Phone:407-696-4474
Practice Address - Fax:407-696-1001
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26160122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program