Healthcare Provider Details

I. General information

NPI: 1760400659
Provider Name (Legal Business Name): JULIA E CORREAL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 STONECREST BLVD STE 104
TEGA CAY SC
29708-6633
US

IV. Provider business mailing address

1188 STONECREST BLVD
TEGA CAY SC
29708-6632
US

V. Phone/Fax

Practice location:
  • Phone: 888-764-5314
  • Fax: 888-764-5314
Mailing address:
  • Phone: 888-764-5314
  • Fax: 888-764-5314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number048104
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8825
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: