1972282317 NPI number — DR. CARLOS MAURICIO HENAO ORTEGA DDS

Table of content: DR. CARLOS MAURICIO HENAO ORTEGA DDS (NPI 1972282317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972282317 NPI number — DR. CARLOS MAURICIO HENAO ORTEGA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENAO ORTEGA
Provider First Name:
CARLOS
Provider Middle Name:
MAURICIO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972282317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24515 ROSETTE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALENCIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91354-3036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-315-6999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25044 PEACHLAND AVENUE SUITE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90089-5746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-287-4352
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  109335 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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