Provider Demographics
NPI:1487737052
Name:CARRILLO HERNANDEZ, JOSE EFRAIN (DENTIST)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:EFRAIN
Last Name:CARRILLO HERNANDEZ
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 WEST COURT
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695
Mailing Address - Country:US
Mailing Address - Phone:530-668-5500
Mailing Address - Fax:530-668-5508
Practice Address - Street 1:58 WEST COURT
Practice Address - Street 2:WOODLAND FAMILY DENTAL
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-668-5500
Practice Address - Fax:530-668-5508
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51902122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD51902OtherDENTICAL