Provider Demographics
NPI:1255578050
Name:CARRILLO, BRYANT
Entity type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:
Last Name:CARRILLO
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 1:8890 CAL CENTER DIVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826
Mailing Address - Country:US
Mailing Address - Phone:916-922-5000
Mailing Address - Fax:916-646-9000
Practice Address - Street 1:8890 CAL CENTER DIVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826
Practice Address - Country:US
Practice Address - Phone:916-922-5000
Practice Address - Fax:916-646-9000
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58020122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist