Healthcare Provider Details

I. General information

NPI: 1558869917
Provider Name (Legal Business Name): WALLACE CARRILLO-MEDINA DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 02/24/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 GREENSBORO ST
ASHEBORO NC
27203-4736
US

IV. Provider business mailing address

511 GREENSBORO ST
ASHEBORO NC
27203-4736
US

V. Phone/Fax

Practice location:
  • Phone: 732-692-6929
  • Fax:
Mailing address:
  • Phone: 336-629-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9900
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: WALLACE CARRILLO-MEDINA
Title or Position: PRESIDENT
Credential: DMD PA
Phone: 336-629-3112