Healthcare Provider Details

I. General information

NPI: 1962790006
Provider Name (Legal Business Name): DR. LUIS PEDRO MIRON CARCAMO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S PROSPECT AVE STE 201
CHAMPAIGN IL
61820-7054
US

IV. Provider business mailing address

1701 S PROSPECT AVE STE 201
CHAMPAIGN IL
61820-7054
US

V. Phone/Fax

Practice location:
  • Phone: 217-305-7980
  • Fax:
Mailing address:
  • Phone: 217-305-7980
  • Fax: 509-488-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019030115
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60448654
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: