MEDICARE: DR. CARLOS VALLECILLO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5778	AZ

General Provider Information

NPI Number	:	1134268873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS VALLECILLO DDS

Provider Business Mailing Address
First Line	:	936 E WILLIAMS FIELD RD
Second Line	:	SUITE 101
City	:	GILBERT
State	:	AZ
Zip	:	85296-4881
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	936 E WILLIAMS FIELD RD
Second Line	:	SUITE 101
City	:	GILBERT
State	:	AZ
Zip	:	85296-4881
Country	:	US
Telephone Number	:	480-722-7600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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