Provider Demographics
NPI:1558649947
Name:CARRILLO-MEDINA, WALLACE (DMD)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:CARRILLO-MEDINA
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 1:101 NORTHPOINT AVE
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7719
Mailing Address - Country:US
Mailing Address - Phone:336-883-6450
Mailing Address - Fax:336-883-6451
Practice Address - Street 1:101 NORTHPOINT AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7719
Practice Address - Country:US
Practice Address - Phone:336-883-6450
Practice Address - Fax:336-883-6451
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0554541223G0001X
NC99001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice