# WALLACE CARRILLO-MEDINA DMD MS PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1689290173
- **Authorized official:** DR. WALLACE C CARRILLO-MEDINA DMD (PRESIDENT)
- **Authorized official phone:** (336) 629-3112

## Contact information

- **Practice address:** 511 GREENSBORO ST, ASHEBORO, NC 27203-4736
- **Practice address phone:** (336) 629-3112
- **Practice address fax:** (336) 629-4251
- **Mailing address:** 511 GREENSBORO ST, ASHEBORO, NC 27203-4736
- **Mailing address phone:** (336) 629-3112
- **Mailing address fax:** (336) 629-4251

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223X2210X | Orofacial Pain Dentistry | — | NULL | Yes |
| 1223X2210X | Orofacial Pain Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 06/19/2020
- **Last updated:** 06/19/2020