Provider Demographics
NPI:1194777532
Name:CARBAJAL, M ZAIDA (DDS)
Entity type:Individual
Prefix:
First Name:M
Middle Name:ZAIDA
Last Name:CARBAJAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4581 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-7967
Mailing Address - Country:US
Mailing Address - Phone:909-393-2239
Mailing Address - Fax:
Practice Address - Street 1:611 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3223
Practice Address - Country:US
Practice Address - Phone:909-235-4148
Practice Address - Fax:909-235-4636
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB41065-01Medicaid