Provider Demographics
NPI:1427719491
Name:CEBALLOS, CARLA VANESSA
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:VANESSA
Last Name:CEBALLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 W VALENCIA DR APT A
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4043
Mailing Address - Country:US
Mailing Address - Phone:914-268-1016
Mailing Address - Fax:
Practice Address - Street 1:1336 W VALENCIA DR APT A
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4043
Practice Address - Country:US
Practice Address - Phone:914-268-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist