Provider Demographics
NPI:1336562875
Name:CARRILLO, ERICA AVILA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:AVILA
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 BROADMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-1806
Mailing Address - Country:US
Mailing Address - Phone:661-427-1943
Mailing Address - Fax:
Practice Address - Street 1:1014 BROADMOOR AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-1806
Practice Address - Country:US
Practice Address - Phone:661-427-1943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73796126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant