Healthcare Provider Details

I. General information

NPI: 1164300067
Provider Name (Legal Business Name): DIANA CELEMI CORTES CARRILLO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 SANDIFUR PKWY APT 4
PASCO WA
99301-9068
US

IV. Provider business mailing address

9720 SANDIFUR PKWY APT 4
PASCO WA
99301-9068
US

V. Phone/Fax

Practice location:
  • Phone: 509-543-4948
  • Fax:
Mailing address:
  • Phone: 509-543-4948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDENT.DE.70016957
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: