Provider Demographics
NPI:1598659146
Name:MARTIN PERDOMO, CARLOS MANUEL
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:MANUEL
Last Name:MARTIN PERDOMO
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 1:730 HARRISON AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07029-1909
Mailing Address - Country:US
Mailing Address - Phone:786-203-3231
Mailing Address - Fax:
Practice Address - Street 1:730 HARRISON AVE APT 2A
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NJ
Practice Address - Zip Code:07029-1909
Practice Address - Country:US
Practice Address - Phone:786-203-3231
Practice Address - Fax:786-203-3231
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI03096800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist