=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891269262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CESAR CARRASCO DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2019
-----------------------------------------------------
Last Update Date | 03/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21847 S AVALON BLVD
-----------------------------------------------------
City | CARSON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-549-9710
-----------------------------------------------------
Fax | 310-549-4049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21847 S AVALON BLVD
-----------------------------------------------------
City | CARSON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-549-9710
-----------------------------------------------------
Fax | 310-549-4049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CESAR E CARRASCO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-392-9634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------