Healthcare Provider Details

I. General information

NPI: 1164123717
Provider Name (Legal Business Name): CARLA BRASIL CAMPOS COELHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 W CHERRY LN APT 215
CARLSBAD NM
88220-8880
US

IV. Provider business mailing address

780 W CHERRY LN APT 215
CARLSBAD NM
88220-8880
US

V. Phone/Fax

Practice location:
  • Phone: 617-620-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDB-2025-0375
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: