Provider Demographics
NPI:1750520466
Name:VICTOR H. CARRILLO PROFESSIONAL DENTAL CORP.
Entity type:Organization
Organization Name:VICTOR H. CARRILLO PROFESSIONAL DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:H
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-420-2231
Mailing Address - Street 1:333 H STREET,
Mailing Address - Street 2:STE 1015
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-420-2231
Mailing Address - Fax:619-420-2312
Practice Address - Street 1:333 H STREET,
Practice Address - Street 2:STE 1015
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-420-2231
Practice Address - Fax:619-420-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty