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General NPI Number Information
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NPI Number | 1558869917
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Entity Type | Organization
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Legal Business Name | WALLACE CARRILLO-MEDINA DMD PA
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Dates
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Enumeration Date | 01/30/2018
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Last Update Date | 02/24/2021
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Provider Practice Location Address
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Address Line | 511 GREENSBORO ST
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City | ASHEBORO
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State | NC
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Zip | 27203-4736
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Country | US
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Telephone | 732-692-6929
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Fax |
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Provider Business Mailing Address
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Address Line | 511 GREENSBORO ST
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City | ASHEBORO
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State | NC
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Zip | 27203-4736
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Country | US
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Telephone | 336-629-3112
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | WALLACE CARRILLO-MEDINA
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Credential | DMD PA
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Telephone | 336-629-3112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X2210X
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Taxonomy Name | Orofacial Pain Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 9900
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License Number State | NC
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