Provider Demographics
NPI:1063608586
Name:SANTIAGO, CARLOS JAVIER (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JAVIER
Last Name:SANTIAGO
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 1:4131 UNIVERSITY BLVD S STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4346
Mailing Address - Country:US
Mailing Address - Phone:904-708-1956
Mailing Address - Fax:904-276-4648
Practice Address - Street 1:4131 UNIVERSITY BLVD S STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4346
Practice Address - Country:US
Practice Address - Phone:904-708-1956
Practice Address - Fax:904-276-4648
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13959122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003180200Medicaid