Provider Demographics
NPI:1528111580
Name:ALFONSO, CARLOS (DDS,MS, DIPLOMATE)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:DDS,MS, DIPLOMATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POST AVE # 102
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-3406
Mailing Address - Country:US
Mailing Address - Phone:646-796-2727
Mailing Address - Fax:646-796-7777
Practice Address - Street 1:100 POST AVE # 102
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3406
Practice Address - Country:US
Practice Address - Phone:646-796-2727
Practice Address - Fax:646-796-7777
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04500711223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01680482Medicaid