Healthcare Provider Details

I. General information

NPI: 1851602734
Provider Name (Legal Business Name): CARLO ENRICO GUEVARA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 EAST COMMERCIAL BLVD SUITE 200
FORT LAUDERDALE FL
33308
US

IV. Provider business mailing address

2600 EAST COMMERCIAL BLVD SUITE 200
FORT LAUDERDALE FL
33308
US

V. Phone/Fax

Practice location:
  • Phone: 954-566-0300
  • Fax: 954-566-9066
Mailing address:
  • Phone: 954-566-0300
  • Fax: 954-566-9066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME126871
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN20097
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: