Healthcare Provider Details

I. General information

NPI: 1265153605
Provider Name (Legal Business Name): LUIZ THIAGO PEREIRA DE CARVALHO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2797 SAINT JOHNS BLUFF RD S
JACKSONVILLE FL
32246-3703
US

IV. Provider business mailing address

2797 SAINT JOHNS BLUFF RD S
JACKSONVILLE FL
32246-3703
US

V. Phone/Fax

Practice location:
  • Phone: 904-966-4560
  • Fax:
Mailing address:
  • Phone: 904-966-4560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN31629
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number107746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: