Healthcare Provider Details

I. General information

NPI: 1437776051
Provider Name (Legal Business Name): GLADYS EDITH CARRILLO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WASHINGTON 2107
NUEVO LAREDO MEXICO
88000
MX

IV. Provider business mailing address

4619 SAN DARIO AVE STE 241
LAREDO TX
78041
US

V. Phone/Fax

Practice location:
  • Phone: 867-719-5403
  • Fax:
Mailing address:
  • Phone: 956-999-8250
  • Fax: 956-999-8250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3978869
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: