Provider Demographics
NPI:1558051367
Name:CARBALLOSA FERNANDEZ, ULISES ERNESTO
Entity type:Individual
Prefix:
First Name:ULISES
Middle Name:ERNESTO
Last Name:CARBALLOSA FERNANDEZ
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 1:10803 LAKE AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-1249
Mailing Address - Country:US
Mailing Address - Phone:786-690-1609
Mailing Address - Fax:
Practice Address - Street 1:2203 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3437
Practice Address - Country:US
Practice Address - Phone:440-381-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.004578390200000X
OH30.0281421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program