Provider Demographics
NPI:1104923887
Name:FAUSTO, CARLOS-MARIA VALLARTA
Entity type:Individual
Prefix:DR
First Name:CARLOS-MARIA
Middle Name:VALLARTA
Last Name:FAUSTO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CARLOS-MARIA
Other - Middle Name:VALLARTA
Other - Last Name:FAUSTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:21720 S VERMONT AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2127
Mailing Address - Country:US
Mailing Address - Phone:310-320-0085
Mailing Address - Fax:
Practice Address - Street 1:21720 S VERMONT AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2127
Practice Address - Country:US
Practice Address - Phone:310-320-0085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice