Provider Demographics
NPI:1649473364
Name:CARRASCO, JORGE (DDS)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:CARRASCO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5818 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4218
Mailing Address - Country:US
Mailing Address - Phone:818-779-0819
Mailing Address - Fax:818-779-0820
Practice Address - Street 1:5818 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-4218
Practice Address - Country:US
Practice Address - Phone:818-779-0819
Practice Address - Fax:818-779-0820
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADB35850122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist