Provider Demographics
NPI:1154039626
Name:SEDILLO, CARLOS VALLEJO (RDH)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:VALLEJO
Last Name:SEDILLO
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4342
Mailing Address - Street 2:
Mailing Address - City:SAN FELIPE PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87001
Mailing Address - Country:US
Mailing Address - Phone:505-867-5025
Mailing Address - Fax:505-771-9998
Practice Address - Street 1:8 CEDAR ROAD
Practice Address - Street 2:
Practice Address - City:SAN FELIPE PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87001
Practice Address - Country:US
Practice Address - Phone:505-867-5025
Practice Address - Fax:505-771-9998
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH4264124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist