Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 0401410612 | VA |
NPI | 1003871112 |
---|---|
Provider Name | Dr. Juan Manuel Carrillo |
First Address | Richmond, VA 23238 |
Second Address | Richmond, VA 23238 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
186588 | ANTHEM ID NUMBER (01) | VA |