Provider Demographics
NPI:1861231987
Name:CASTILLA, PATRICIO ELIAS
Entity type:Individual
Prefix:
First Name:PATRICIO
Middle Name:ELIAS
Last Name:CASTILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BISCAYNE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7227
Mailing Address - Country:US
Mailing Address - Phone:305-322-6779
Mailing Address - Fax:
Practice Address - Street 1:230 MAPLE ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5144
Practice Address - Country:US
Practice Address - Phone:413-420-1755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPENDING122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist