MEDICARE: DR. ENID CARABALLO DMD

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	122300000X	Dentist	2022	PR

General Provider Information

NPI Number	:	1225178973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ENID CARABALLO DMD

Provider Business Mailing Address
First Line	:	278 LASALLE LEFALL DR
Second Line	:
City	:	QUINCY
State	:	FL
Zip	:	32351-5324
Country	:	US
Telephone Number	:	850-875-7200
Fax Number	:	850-875-3065

Provider Business Practice Location Address
First Line	:	278 LASALLE LEFALL DR
Second Line	:
City	:	QUINCY
State	:	FL
Zip	:	32351-5324
Country	:	US
Telephone Number	:	850-875-7200
Fax Number	:	850-875-3065

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	03/08/2013

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