Healthcare Provider Details

I. General information

NPI: 1013032333
Provider Name (Legal Business Name): ALFONSO CORREA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 FORT WASHINGTON AVE
NEW YORK NY
10040-3929
US

IV. Provider business mailing address

620 FORT WASHINGTON AVE
NEW YORK NY
10040-3929
US

V. Phone/Fax

Practice location:
  • Phone: 212-923-5777
  • Fax: 212-569-3280
Mailing address:
  • Phone: 212-923-5777
  • Fax: 212-569-3280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number049924
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: