Provider Demographics
NPI:1700075256
Name:VILLACARLOS, MICHAEL ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:VILLACARLOS
Suffix:
Gender:M
Credentials:DDS
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Other - Credentials:
Mailing Address - Street 1:398 192ND ARMORED TANK BATTALION RD, BLDG 1022 RM 231
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5116
Mailing Address - Country:US
Mailing Address - Phone:502-624-6158
Mailing Address - Fax:502-624-2966
Practice Address - Street 1:398 192ND ARMORED TANK BATTALION RD, BLDG 1022 RM 231
Practice Address - Street 2:USA DENTAC
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5116
Practice Address - Country:US
Practice Address - Phone:502-624-6158
Practice Address - Fax:502-624-2966
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ22DI023654001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice