Provider Demographics
NPI:1205921004
Name:CABALLERO, MARIO JAVIER (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:JAVIER
Last Name:CABALLERO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 S. PATRICK DRIVE (BUILDING 1371)
Mailing Address - Street 2:
Mailing Address - City:PATRICK AIR FORCE BASE
Mailing Address - State:FL
Mailing Address - Zip Code:32925-3607
Mailing Address - Country:US
Mailing Address - Phone:305-446-5676
Mailing Address - Fax:305-446-5265
Practice Address - Street 1:1389 S. PATRICK DRIVE (BUILDING 1371)
Practice Address - Street 2:
Practice Address - City:PATRICK AIR FORCE BASE
Practice Address - State:FL
Practice Address - Zip Code:32925-3607
Practice Address - Country:US
Practice Address - Phone:305-446-5676
Practice Address - Fax:305-446-5265
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-115721223G0001X
FLDN11572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice