MEDICARE: DR. ERICO CARRENO 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	1479109	ZZ

General Provider Information

NPI Number	:	1598902777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERICO CARRENO DDS

Provider Business Mailing Address
First Line	:	776 N VALLEY VIEW DR
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91914-2432
Country	:	US
Telephone Number	:	619-308-7082
Fax Number	:

Provider Business Practice Location Address
First Line	:	LUIS CABRERA #1509-1 ZONA RIO
Second Line	:
City	:	TIJUANA
State	:	BAJA CALIFORNIA
Zip	:	22320
Country	:	MX
Telephone Number	:	619-308-7082
Fax Number	:

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

Provider Enumeration Date	:	01/09/2009
Last Update Date	:	01/09/2009

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