Healthcare Provider Details

I. General information

NPI: 1821684713
Provider Name (Legal Business Name): EVERGREEN DENTAL ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 MCCASLIN BLVD STE 200
LOUISVILLE CO
80027-2932
US

IV. Provider business mailing address

357 MCCASLIN BLVD STE 200
LOUISVILLE CO
80027-2932
US

V. Phone/Fax

Practice location:
  • Phone: 970-699-8954
  • Fax:
Mailing address:
  • Phone: 970-699-8954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: NATHAN JAMES CARILLO
Title or Position: PRESIDENT/OWNER
Credential: D.D.S.
Phone: 562-673-8732