Healthcare Provider Details

I. General information

NPI: 1841647294
Provider Name (Legal Business Name): NATHAN JAMES CARILLO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
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 NumberDEN.00204375
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: