Provider Demographics
NPI:1790678134
Name:PAEZ CARRILLO, NELSON (DMD)
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:PAEZ CARRILLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TECHNOLOGY PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7122
Mailing Address - Country:US
Mailing Address - Phone:407-543-8514
Mailing Address - Fax:
Practice Address - Street 1:2710 BLANDING BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-5650
Practice Address - Country:US
Practice Address - Phone:904-637-1148
Practice Address - Fax:904-302-9392
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN303291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice