Provider Demographics
NPI:1609012830
Name:CAMPO, CARLA PATRICIA (DDS)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:PATRICIA
Last Name:CAMPO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3702
Practice Address - Street 1:30195 FRASER DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7006
Practice Address - Country:US
Practice Address - Phone:951-252-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1871689315Medicaid