Provider Demographics
NPI:1710025499
Name:MACHADO, CAMILO (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:CAMILO
Middle Name:
Last Name:MACHADO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31315 HARPER AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082
Mailing Address - Country:US
Mailing Address - Phone:586-293-3434
Mailing Address - Fax:614-292-9422
Practice Address - Street 1:31315 HARPER AVENUW
Practice Address - Street 2:
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082
Practice Address - Country:US
Practice Address - Phone:586-293-3434
Practice Address - Fax:586-293-4460
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH71-0001891223P0700X
MI1710025499122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH71000189OtherOHIO STATE LICENSE NUMBER