MEDICARE: CORO ORTHODONTICS 2 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1407310808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORO ORTHODONTICS 2 LLC

Provider Business Mailing Address
First Line	:	896 S DIXIE HWY
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2604
Country	:	US
Telephone Number	:	305-661-9798
Fax Number	:

Provider Business Practice Location Address
First Line	:	896 S DIXIE HWY
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2604
Country	:	US
Telephone Number	:	305-661-9798
Fax Number	:

Authorized Official
Title or Position	:	AMBR
Name	:	JORGE CORO
Credential	:	DMD, MS
Telephone Number	:	305-661-9798

Provider Enumeration Date	:	01/30/2019
Last Update Date	:	01/30/2019

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