Healthcare Provider Details

I. General information

NPI: 1639571789
Provider Name (Legal Business Name): MICHAEL DE CORO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E SCHOOL AVE
VISALIA CA
93291-5032
US

IV. Provider business mailing address

305 E CENTER AVE
VISALIA CA
93291-6331
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: