Healthcare Provider Details

I. General information

NPI: 1619281086
Provider Name (Legal Business Name): DR. EDGAR ALEJANDRO CARRASCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 FARMINGTON AVE
HARTFORD CT
06105-4423
US

IV. Provider business mailing address

436 FARMINGTON AVE
HARTFORD CT
06105-4423
US

V. Phone/Fax

Practice location:
  • Phone: 860-233-7777
  • Fax: 860-523-0642
Mailing address:
  • Phone: 860-233-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number11886
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: