Provider Demographics
NPI:1750999074
Name:CARRASCO, GEORGINA (DMD)
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12938 CARMEL CREEK RD UNIT 77
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:807 CAMINO DEL MAR APT 2030
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2810
Practice Address - Country:US
Practice Address - Phone:480-823-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1050051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice