Provider Demographics
NPI:1861225401
Name:CARRILLO, ESTIVALI
Entity type:Individual
Prefix:
First Name:ESTIVALI
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25748 SW CANYON CREEK RD APT A303
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-5620
Mailing Address - Country:US
Mailing Address - Phone:626-423-4002
Mailing Address - Fax:
Practice Address - Street 1:2725 SW CEDAR HILLS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1435
Practice Address - Country:US
Practice Address - Phone:503-352-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH8898124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist