Provider Demographics
NPI:1023102357
Name:DORANTES, CARLOS (DDS)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:DORANTES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 SUMMITVIEW AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3027
Mailing Address - Country:US
Mailing Address - Phone:509-966-4433
Mailing Address - Fax:509-966-1021
Practice Address - Street 1:6201 SUMMITVIEW AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3027
Practice Address - Country:US
Practice Address - Phone:509-966-4433
Practice Address - Fax:509-966-1021
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000095671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5044078Medicaid
WA0172070OtherL & I
911019392OtherCOMMERCIAL